Annual report and accounts

Annual report and accounts: 1 April 2024 to 31 March 2025. Presented to Parliament pursuant to Schedule 7 paragraph 25 (4) (a) of the National Health Service Act 2006.

Contents

1.1 – The Performance Report (Overview of Performance)

1.2 – The Performance Report (Performance Analysis)

2.1 – The Accountability Report (Director’s Report)

2.2 – The Accountability Report (Remuneration Report)

2.3 – The Accountability Report (Staff Report)

2.4 – The Accountability Report (Disclosures required in the Annual Report)

2.5 – The Accountability Report (NHS Oversight Framework)

2.6 – The Accountability Report (Statement of Accounting Officer’s Responsibilities)

2.7 – The Accountability Report (Annual Governance Statement)

3 – The Board of Directors (further information)

4 – The Council of Governors

5 – Membership (further information)

6 – Our auditors

Part B – The Annual Accounts and Auditor’s Report

Contact Information

1.1 – The performance report (Overview of Performance)

The purpose of the Overview Section is to provide a short summary setting out our purpose, key risks to the achievement of our objectives and how we have performed during the year.

1.1.1 – A message from our Chair

This is a time of significant change in the NHS, with reorganisations at NHS England and the Department for Health and Social Care which, from the perspective of provider trusts, will bring even sharper focus on core performance and financial management. Finances are particularly challenging, with the NHS nationally projected to overspend by several billion pounds unless we can all do our bit to get to a better position. For us, however, this doesn’t change our key priorities, which involve examining the areas where we can best improve both the experiences of our service users and our core costs. This includes reducing the number of times when we have to send some of our inpatients to another area because we do not have a bed available in our own service. Sometimes there are good reasons for someone wanting to be out of Leeds although generally people prefer to stay closer to home and family and we want to make sure this can happen. We are looking at every aspect of this, including admittance and discharge work and are already seeing good results, led by hard work by many of our teams. Another area we are focussing on is trying to reduce the number of interim and agency staff we need to rely on. This covers a huge amount of work such as looking at how medical and nursing students can be encouraged into mental health careers; how we attract professionals to LYPFT, including dieticians, occupational therapists, pharmacists and many more; how we train and develop our own staff onto career pathways, such as nursing apprenticeships and how we make LYPFT a good place to work, so that our staff stay with us. Again, lots of hard work by many and I am proud of the efforts everyone is making on all of our priorities.

Reflecting on last year’s report I remember noting a lot of changes to the Board. I am pleased that this year we have seen a lot of stability, with no new changes to report. Board members have been able to mix new perspectives with growing familiarity with each other as a team and I have seen this work well both at formal Board meetings and in our development sessions. At the time of writing this we have just completed a well led review into our Board and governance arrangements, which I am pleased to say found that “The Board is a credible and capable team which is clearly sighted on the issues facing the Trust and the Board”.

With our Council of Governors, however, we have seen many changes as terms of office came to an end and new governors join us. Les France ended his term as Lead Governor after serving several years in this role. I would like to thank Les who brought a lot of dedication to this role and was very supportive to me as a new Chair. Les will remain on the Council of Governors as a public governor. Following an election process, however, I am pleased to say that we now have another experienced governor taking on the Lead Governor role; Ian Andrews. Ian is a staff governor and puts a lot of thought into the role so I know he will be an excellent Lead Governor. Overall, the Council of Governors continues to show great commitment in what is an unpaid role, providing great insight and challenge to our work.

In the midst of all of our challenges the one thing that remains constant is the high quality of care and compassion shown by all our teams. Once again, throughout this year, I have seen this for myself during visits to different services, as well as hearing from different staff teams presenting to the Board. It is a constant reminder of how diverse our services are, from national and regional teams to very local ones. I am always particularly struck by how hard our staff work to meet the needs of service users as distinct individuals, with different needs and desires, and how important this is in upholding our values. Every year I am also seeing our commitment to co-production growing and having real impact. We have service users who put a huge amount of work into this, both through formal mechanisms such as our Service User Network and as service user governors, and through less formal ways such as participating in ward meetings and helping out on research projects. Our staff and service users go the extra mile in everything they do and the Board is enormously proud of their efforts.

Finally, partnership working across organisations in Leeds and West Yorkshire continues to grow. This year I chaired the committee that we share with the other mental health, learning disability and neurodiversity trusts in West Yorkshire: Bradford District Care NHS Foundation Trust; South West Yorkshire Partnership NHS Foundation Trust and Leeds Community Healthcare NHS Trust. We have covered quite a range of issues including the establishment of a shared staff bank and looking at shared learning on finance, while continuing to deliver services where one organisation acts as lead provider on behalf of all; for example, we lead on tier 4 Children and Young People’s Mental Health Services at Red Kite View. This is an important forum for making sure we are all working together for communities across West Yorkshire or the wider region.

Our Executive Team also support the partnership working of the West Yorkshire Integrated Care Board, the Leeds Place Board and the Leeds Health and Wellbeing Board, as well as many of the committees and project groups associated with these. This is particularly important at the moment as we have to share our financial pressures across ten Trusts in West Yorkshire so that we balance our accounts as a group but it is also a crucial part of making sure we all join up in the best way to serve our communities.

I would like to thank my Board colleagues, executive and non-executive, and the governors for all their efforts in ensuring we are a well led organisation, and our staff and involved service users for their dedication and commitment to making sure we deliver the best quality care.

1.1.2 – A message from our Chief Executive

As we reflect on the past year at Leeds and York Partnership NHS Foundation Trust, I want to express my gratitude to our dedicated staff, service users, and partners. Despite the challenges faced, we have made significant progress in improving mental health services, tackling inequalities, and fostering a culture of compassion and innovation. I am privileged to lead such committed and talented people who work tirelessly all year round to provide great care or who provide the conditions for great care to happen.

The increasing demand for mental health services, particularly in adult acute care, has required a concerted effort from our teams. Through our Improving Patient Flow programme, we have significantly reduced out-of-area placements, enhanced timely discharges, and improved bed management to ensure that those in crisis receive the right support at the right time. The launch of the NHS 111 mental health helpline has provided a crucial lifeline for those in urgent need. At the same time, a new pilot scheme allows our acute teams to respond to certain mental health-related 999 calls, reducing unnecessary hospital admissions and improving crisis response.

The transformation of community mental health services across Leeds has gained momentum, with our early implementer sites showing promising results. Our Crisis Resolution Intensive Support Service (CRISS) has been restructured into three crisis and home treatment teams, ensuring a more streamlined and effective service. We have continued strengthening our partnerships with primary care and voluntary sector organisations to provide holistic and accessible mental health support.

Our Adult ADHD Service has faced difficult but necessary decisions, including pausing non-urgent referrals to focus on those with the greatest clinical need. At the same time, we developed a sustainable, long-term solution that improves access for all. The National Deaf Child and Adolescent Mental Health (North) Service is running a mental health assessment service for deaf adults aged 18-25; the pilot programme will provide an assessment/diagnostic service, with short-term intervention sessions where appropriate, at our site in York.

We know that people with serious mental illness die on average 15 to 20 years earlier than the general population. Additionally, individuals with a learning disability are 3 to 4 times more likely to die from avoidable medical causes. Those with neurodiverse conditions often face significant challenges in accessing timely services and treatments, which results in poorer health and reduced life opportunities. Addressing health inequalities remains at the core of our mission. Our first Improving Health Equity Strategy, led by Joanna Forster Adams, Chief Operating Officer, Sophie Valinakis, Head of Health Equity, and Dr Anna Ray, Consultant in Public Health, provides a framework to ensure better access to services and improved health outcomes. By embedding health equity principles across our organisation, we are taking meaningful steps to bridge gaps in care and tackle the social determinants of health that disproportionately affect the people we serve.

Supporting our staff remains a top priority. We recognise our teams’ immense dedication and hard work and are committed to fostering a positive and inclusive workplace culture. We continue to prioritise wellbeing initiatives to support staff retention and satisfaction, and our “Spotlight” recognition platform has empowered colleagues to celebrate each other’s contributions. I am committed to supporting the Spotlight platform and taking the opportunity to recognise individuals and teams every week for their work. This year, many of our colleagues have received national awards and accreditations, showing how we’re “leading the way in mental health, learning disability and neurodiversity care”.

Our Chaplaincy Team has continued its journey to becoming multi-faith with two new members and have seen the distribution of multi-faith chaplaincy resource boxes and training for staff on supporting service users from different faith backgrounds. They have introduced drop-in events and multi-faith room user group meetings to meet the needs of those who use them. Looking ahead, volunteer chaplains from diverse faith communities will begin offering support across multiple sites, further strengthening our inclusive approach to spiritual care.

We remain committed to fostering an inclusive and supportive workplace. Our values-based recruitment programme has progressed, ensuring we recognise lived experience as an asset. We also continue to embed collective leadership, strengthening collaboration across teams.

Our partnerships with local organisations and research institutions have driven innovation in mental health services. This year, we launched a new clinical research hub, furthering our commitment to evidence-based practice. We have also continued our collaboration with third-sector partners, delivering impactful initiatives to support mental health recovery and wellbeing in the community.

Financial sustainability has also been a focus, and through careful planning, we have reduced our reliance on agency staff and identified efficiencies in corporate services to ensure that we direct our resources towards frontline care. Additionally, significant investment has gone into upgrading our digital infrastructure to improve accessibility and efficiency. Introducing an electronic document management system has streamlined administrative processes, enabling clinicians to spend more time with patients.

Patient safety remains at the heart of everything we do. In 2024, we adopted the Patient Safety Incident Response Framework (PSIRF), shifting towards a learning-focused, non-punitive approach to incident management. This new model reinforces our commitment to transparency, fairness, and continuous learning, ensuring that we apply insights from past experiences to improve outcomes for our service users.

The redevelopment of Parkside Lodge as the new home for our High-Intensity Rehabilitation Service marks a major milestone, ensuring that those with complex needs receive high-quality, person-centred care in a modern and supportive environment and adapting to new national commissioning guidelines. These infrastructure improvements are a testament to our commitment to innovation and service enhancement.

Our Perinatal Mental Health Service received a boost from the Care Quality Commission (CQC) following an unannounced inspection earlier in the year. The CQC gave them an overall rating of ‘good’. The inspection team said we should be “pleased with the findings of [their] report, which highlights many areas of good practice and a positive environment for people needing help and support.” In April 2025, we will take on the role of lead provider for perinatal mental health services within the region, with plans to expand inpatient care for mothers and babies later in the year.

Our refreshed five-year strategy, Improving the Health and Lives of the Communities We Serve, will shape our priorities and drive forward innovation, integration, and person-centred care, describing who we are, where we’re going and how we plan to get there. The strategy also showed off our refreshed brand and visual identity, which we’d spent the previous year co-developing with staff, people with lived experience, and health and care partners. One specific element of our refreshed brand is our new Trust strapline, developed in response to feedback about the ambiguity of the Trust’s name. The strapline we adopted is: “Leading the way in mental health, learning disability and neurodiversity care.”

I want to sincerely thank our staff, service users, and partners for their unwavering dedication, resilience, and passion. Your commitment makes a real difference in people’s lives.

1.1.3 – About our Trust – a brief history and statutory background

As part of the NHS and Community Care Act (1990) the Leeds Community and Mental Health Services Teaching NHS Trust was formed on 1 February 1993. This was a self-governing trust providing community, mental health and learning disability services within the Leeds metropolitan area. In 2002 the community services previously provided by the NHS Trust transferred to the PCTs in Leeds, and the Trust was renamed the Leeds Mental Health Teaching NHS Trust; providing only mental health and learning disability services.

On 1 August 2007 NHS England (formally Monitor) authorised us as a foundation trust, and we were formed as the Leeds Partnerships NHS Foundation Trust under the NHS Act 2006. As a foundation trust we provide mental health and learning disability services and have freedoms to act which NHS trusts don’t.

A further development for our Trust was the acquisition of mental health, learning disability and substance misuse services from NHS North Yorkshire and York and NHS England on 1 February 2012. To reflect the new geographical area in which services were provided we became the Leeds and York Partnership NHS Foundation Trust. However, the services commissioned by NHS North Yorkshire and York transferred to Tees, Esk and Wear Valleys NHS Foundation Trust on 1 October 2015, although the Trust still provides specialist services commissioned by NHS England from its York bases to a regional population.

1.1.4 – Our strategy

Improving the Health and Lives of the Communities we Serve: from 2025 to 2030 is the new five-year strategy of Leeds and York Partnership NHS Foundation Trust. It was developed during 2024, ratified by the Trust Board in November that year and has been socialised internally and externally during quarter four of 2024/25.

During its nine-month development process, the Trust consulted with its Council of Governors as well as its three staff networks, its service user network, and various other internal and external partners. Governors were invited to contribute to the development of the strategy through an in-person workshop and through feedback forms.

The strategy, and its underpinning five strategic plans, can be found on Our Strategy page.

1.1.4.1 – Our new strategic narrative

Prior to developing its new five-year strategy, the Trust embarked on a brand refresh exercise where new strategic narrative statements were developed, alongside a new bold and ambitious visual identity. This included the development of an organisational ‘strapline’ in response to feedback about the name of the Trust being ambiguous.

Our strapline is “Leading the way in mental health, learning disability and neurodiversity care.”

Our vision and mission statements are the building blocks of our identity. Our vision is our aspiration, and our mission is how we want to achieve it.

Our vision is:
To lead the way in mental health, learning disability and neurodiversity care so the communities we serve can live healthy and fulfilling lives, our people can achieve their personal and professional goals, and everyone can live their lives free from stigma and discrimination.

Our mission is:
To improve the health and lives of the communities we serve by providing outstanding mental health, learning disability and neurodiversity services; to be a great place to work and a great partner to work with.

Our promise:
We see over a million service users and carers every year. Our promise to them is that we are dedicated to people-centred care and are proud of the high-quality, specialist mental health, learning disability and neurodiversity services we provide. We actively involve people in their care to empower them to achieve their personal goals and enjoy fulfilling lives.

1.1.4.2 – Our strategic plans

Our five-year strategy is designed to be a simple and accessible explanation of who we are, what we’re here for, what we’re going to do, and how, to improve the health and lives of the communities we serve.

The detail of what, how, when and by whom, is contained within our five underpinning strategic plans:

  • Care Services Strategic Plan
  • Digital Plan
  • Estates Strategic Plan
  • People Plan
  • Quality Strategic Plan
  • Green Plan

The Estates Strategic Plan was refreshed during 2024/25 and was ratified at Trust Board in March 2025.

All are available on Our Strategy page.

1.1.5 – Our values and behaviours

Our values and behaviours describe what attitudes and behaviours we believe are important in achieving our purpose. A key part of our strategy development focused on the values and behaviours our staff are committed to deliver. In 2024/25 we published an updated Values and Behaviours Charter, incorporating some of the key messages from our work on civility and respect which was led by the People and Organisational Development directorate.

Our values and behaviours are set out below.

Table 1.1B – Our values and behaviours

Our values Behaviours that uphold our values
We have integrity
We treat everyone with respect and dignity, honour our commitments and do our best for our service users and colleagues.
  • We are committed to continuously improving what we do because we want the best for our service users.
  • We consider the feelings, needs and rights of others.
  • We give positive feedback as a norm and constructively challenge unacceptable behaviour.
  • We’re open about the actions we take and the decisions we make, working transparently and as one team with service users, colleagues and relevant partner organisations.
We keep it simple
We make it easy for the communities we serve and the people who work here to achieve their goals.
  • We make processes as simple as possible.
  • We avoid jargon and make sure we are understood.
  • We are clear what our goals are and help others to achieve their goals.
We are caring
We always show empathy and support those in need.
  • We make sure people feel we have time for them when they need it.
  • We listen and act upon what people have to say.
  • We communicate with compassion and kindness.

1.1.6 – Statement of purpose and activities of the Trust

We are a provider of specialist mental health and learning disability services. As a teaching trust with strong links to local universities we have a reputation as a centre of excellence for teaching, research and development, partly attributable to the national profiles of a number of our clinicians.

Leeds and York Partnership NHS Foundation Trust is the main provider of specialist mental health and learning disability services in Leeds. We also provide adult neurodiversity services in Leeds; we provide specialist services across West Yorkshire and Humber and North Yorkshire, and some highly specialised services across the North of England. We have developed robust relationships with service users, carers and our partners in the NHS, Local Authorities and third sectors.

We provide services to approximately 836, 987 individuals in the Leeds areas and specialist services and accept referrals from across the UK. We operate from around 60 buildings across a number of sites and employ approximately 3363 staff and 590 bank staff.

Clinical services are currently delivered across nine service lines:

  • Acute services
  • Learning Disabilities services
  • Perinatal and Liaison services
  • Older People’s Services
  • Children and Young Peoples’ Mental Health Services (CYPMHS)
  • Regional Eating Disorders and Rehabilitation services
  • Forensic services
  • Community and Wellbeing services
  • Regional and specialist services

Our services are delivered across a range of settings in Yorkshire and the Humber and our Deaf Children and Young Peoples’ Mental Health Service operates from Manchester and Newcastle. They are commissioned by a range of commissioners, including national specialised commissioning (NHS England), Integrated Care Boards, the Local Authority and Public Health. A number of our services are also delivered through formal partnerships with other agencies. The services we provide include:

  • Community Mental Health Teams
  • Care Home Team
  • Memory Service
  • Crisis Assessment Services
  • Intensive Community Services including the Home-Based Treatment Team
  • Younger People with Dementia Team
  • Psychological and Psychotherapy Services
  • Assertive Outreach Team
  • Older People’s Liaison Mental Health Service (based at St James’s Hospital)
  • Mental Health Inpatient Services
  • Dementia Inpatient Service
  • Rehabilitation and Recovery Services
  • Healthy Living Service.
  • Forensic Services
  • Children and Young Peoples’ Tier 4 Inpatient Mental Health Services
  • Learning Disability Services
  • Eating Disorders Services
  • Gender Identity Services
  • Liaison Psychiatry
  • National Deaf Children and Families Service
  • Northern School of Child and Adolescent Psychotherapy (NSCAP) Clinical Services
  • Perinatal Services
  • Personality Disorder Services
  • OpCourage Service
  • Addictions Plus Service

1.1.7 – Principal risks and opportunities for the organisation

1.1.7.1 – Risks

Key or principle risks for the organisation are those that have been identified as strategic risks on the strategic risk register which populate our Board Assurance Framework (BAF). Each of these risks has an identified executive director and management lead. The risks are managed through the risk management, risk register and operational planning processes. They are reported to the Executive Risk Management Group, Board sub-committees and the Board through the BAF. Behind each risk is a detailed risk assessment which sets out the controls and mitigations.

The Board has assessed its risk appetite which is ‘open’ to considering all potential options and solutions. It is classed as ‘high’ in relation to that openness, but the Board would not take risks that either compromise the Trust’s compliance with its duty of care to staff and service users or compromise compliance with the core regulatory and legislative frameworks within which it has a licence to operate. These risks set the context in which the Board and its sub-committees carry out their roles.

The Board and its committees continue to keep the risks under review at each meeting to gain assurances on the actions being taken and to understand the impact on performance and future plans.

During 2024/25 the Board considered and refreshed the strategic risks to ensure the strategic risks reflect the key issues that could affect the Trust in delivering its objectives and / or its future success and sustainability. The Board did this through workshops and in consultation with the Board committees. The Board signed off the refreshed risks in March 2025. Following the finalisation of the Trust’s strategic objectives for 2025/26, the BAF strategic risks will be reviewed to ensure that they are reflective of the key risks associated with the delivery of the Trust priorities and objectives. This will be reviewed on an ongoing basis via the Board and committees in line with good governance and risk management processes.

In summary the key strategic risks are described as follows:

Table 1.1C – Our key strategic risks
Strategic risks Linked to Strategic Objective:
SR1 – If there is a breakdown of quality including safety assurance processes, we risk not being able to maintain standards of safe practice, meeting population health needs and compliance with regulatory requirements. Through our Care Services: we deliver great care that is high quality and improves lives
SR2 – There is a risk that we fail to make the improvements outlined in the Quality Strategic Plan and that this has an impact on how we understand and act on the care of those who use our services. Through our Care Services: we deliver great care that is high quality and improves lives
SR3 – There is a risk that we fail to deliver a culture and environment that recruits, retains, and attends to the wellbeing of staff to enable them to be their best and deliver quality services now and in the future. For our People: we provide a rewarding and supportive place to work.
SR4 – There is a risk that a lack of financial sustainability results in the destabilisation of the organisation and an inability to meet our objectives. Using our resources wisely: we deliver effective and sustainable services.
SR5 – Due to an inability to provide adequate working and care environments we risk being unable to deliver safe and effective services. Using our resources wisely: we deliver effective and sustainable services.
SR6 – As a result of insecure, inadequate and poorly utilised digital technologies there is a risk the quality and continuity of services is compromised. Using our resources wisely: we deliver effective and sustainable services.
SR7 – There is a risk we fail to understand, plan and deliver services that meet the health needs of the population we serve. Through our Care Services: we deliver great care that is high quality and improves lives.

1.1.7.2 – Opportunities

The opportunities for the Trust focus on developing our services and partnerships. Working in partnership provides us with an opportunity to work cohesively across geographical areas to ensure there is a seamless provision of care for our service users. In 2023, the Trust published its Care Services Strategic Plan which identified a number of priorities and objectives. One of these focusses on our partnerships and this has been the focus of activities during 2024/25 resulting in strengthened relationships with partners.

Priority 2 Objectives for priority 2
We collaborate with our partners to understand our populations and provide proactive integrated care
  • We understand who our partners are (both across the ICS and place) and create the right environments to work with them
  • We stay informed about our populations and their holistic care needs and proactively support people
  • We co-design and co-deliver proactive integrated care and support with our partners

The Trust values working in partnership and recognises the positive impact this has on service users’ experience and we will continue to develop partnerships through 2025/26 using the framework and approach illustrated below:
A pyramid diagram illustrating five ascending levels of engagement and formality in relationships. From bottom to top, the levels are: 1) Informal networking and relationship building (e.g., specialist care forums, business leaders' networks), 2) Involvement (e.g., Older People's Forum, CMHT Engagement and Involvement Group), 3) Formal Networking (e.g., Partnership Forums, third sector forum), 4) Joint Working (e.g., Liaison Service, CMHTs Memorandums of Understanding), and 5) Contractual Financial Relationship (e.g., Partnership agreement, provider collaborations, subcontracts, Op Courage). An arrow on the right side of the pyramid indicates 'Increasing formality and engagement' as you move upward.

Caption: A pyramid visualising the increasing levels of formality and collaboration in partnership working, from informal networking to contractual financial relationships.

1.1.7.3 Our wider partnership context

We operate within a health and care system and we work with partners to join up care pathways to improve outcomes for the people who use our services. We provide many of our services in collaboration with our partners in our place and Integrated Care Systems, as well as regionally and nationally.

We have agreed to work in partnership with other members of the West Yorkshire Health and Care Partnership to provide services across and beyond West Yorkshire. We work together to deliver the best possible care, experience, and outcomes for people within the available resources. Each collaborative organisation has a governance structure and partnership agreement that provides assurance through to a Committees in Common which was established to oversee the system-wide programme to deliver this collaborative model of care.

In West Yorkshire we currently have four Provider Collaboratives.

  • LYPFT is the lead provider for Tier 4 Children and Young Peoples Mental Health Services.
  • LYPFT is the lead Provider for Adult Eating Disorders (CONNECT)
  • LYPFT is a partner in the Secure Service Provider Collaborative
  • LYPFT is part of the West Yorkshire Assessment and Treatment Units (ATU) collaborative commissioning model, led by Bradford District Care NHS Foundation Trust.
  • LYPFT is the Lead Provider for the Perinatal Mental Health Collaborative across three ICS regions; West Yorkshire, Humber & North Yorkshire and South Yorkshire.

We are also part of the Humber and North Yorkshire Health and Care Partnership, and a partner within the Humber and North Yorkshire Provider Collaborative providing Adult Secure Services and Children and Young Peoples Mental Health Inpatient Services within similar governance and assurance processes to ensure the future sustainability of these services.

Our partnership working is driven through established programme and delivery boards, such as the West Yorkshire Specialised Programme Board and place-based population health boards, including the Mental Health Population Board and the Learning Disability and Neurodiversity Population Board. We hold seats on all the place-based population health boards.  As part of our collaborative we have a West Yorkshire Mental Health, Learning Disability and Autism programme of work. Our Chief Executive is the chair of the Programme Board.

We have an increasing number of partnership working arrangements with third sector partners to deliver key aspects of our services, for example:

  • A mental health alliance to deliver the transformed community mental health services involving Northpoint, Barca-Leeds and Leeds MIND.
  • Aspire – early intervention in psychosis service
  • Mind – peer support workers
  • St Annes– harm reduction workers

The Trust continues to maximise every opportunity to work in partnership where it is to improve the quality of care received by services users and to improve the efficient use of resources.

1.1.8 – Going concern statement

After making enquiries, the directors have a reasonable expectation that the services provided by Leeds and York Partnership NHS Foundation Trust will continue to be provided for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual.

1.1.9 – The environment in which we operate

1.1.9.1 – The national context

In January 2019, NHS England published the NHS Long Term Plan, setting out a ten-year vision for health services in England; showing how it will use the NHS long-term funding settlement that was agreed by the Government in July 2018. The Plan includes proposals that are relevant specifically to the Trust and for the partnerships we work in. The Plan guarantees investment in community services, promoting greater partnership working between primary and community care. The Plan continues the focus on the priorities within the Five Year Forward View for Mental Health and outlines further work on community mental health teams and other aspects of core services, including child and young peoples’ mental health services. The Plan also sets out priorities for learning disability services, autism and neuro-developmental conditions, dementia and frailty and outlines work to support digital developments and the use of data, a focus on health inequalities and an emphasis on system working.
Following the last general election the new government is undertaking a significant review of the Department of Health and Social Care and NHS England which will include organisational changes at national and local level and a new ten-year plan due to be published in summer 2025.

1.1.9.2 – The regional context – West Yorkshire Health and Care Partnership

The West Yorkshire Health and Care Partnership is an integrated care system (ICS). ICS’s organise health and care services to support people and communities to be healthier and happier. They bring together partners across one area, including local councils, the NHS, care providers, charities, and voluntary and community organisations.

The work of the West Yorkshire Health and Care Partnership focuses on four main areas:

  • Improving health and care outcomes for people
  • Addressing health inequalities
  • Increasing productivity and efficiency
  • Supporting broader social and economic development.

Within the West Yorkshire Health and Care Partnership, there is a Partnership Board. The Board is an important group for the Partnership which covers Bradford District and Craven, Calderdale, Kirklees, Leeds, and Wakefield District. Elected members, partner executives, and non-executives are brought together in one decision-making process. Our Chief Executive, Dr Sara Munro, is a Board member. The Partnership also includes a legal organisation known as the NHS West Yorkshire Integrated Care Board (ICB). As a result of the Health and Care Act 2022, the ICB became a statutory organisation from 1 July 2022, meaning it became an officially recognised and authorised body under the law, with the legal power to carry out its responsibilities in the Partnership.

Together across West Yorkshire, the Partnership supports 2.4 million people living in urban and rural areas. 770,000 are children and young people. 530,000 people live in areas ranked as the poorest 10% of England. 20% of people are from minority ethnic communities. There are an estimated 400,000 unpaid carers, as many don’t access support. Together the Partnership employs over 100,000 members of staff and works alongside thousands of volunteers.

The work is carried out across five places – Bradford District and Craven, Calderdale, Kirklees, Leeds, and Wakefield District. This approach, known as place-based working, uses the strengths, abilities, and knowledge of everyone involved.

Across West Yorkshire there are also strong care provider collaboratives, including West Yorkshire Association of Acute Trusts, the Mental Health, Learning Disabilities and Autism Collaborative (MHLDA), the Community Healthcare Collaborative and the Hospice Collaborative. Provider collaboratives are often partnerships between two or more NHS trusts, such as hospitals and mental health services. NHS providers face big challenges, such as more people needing services, and staff recruitment and retention concerns. These challenges are too big for one organisation to handle alone. So, the idea of collaboratives is to bring providers together to tackle these challenges together, whilst sharing good practice.

Working together provides greater opportunities to deliver the West Yorkshire Integrated Care Strategy and Joint Forward Plan – which aims to make sure that all people are given the best start in life and are able to remain healthy and age well.

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1.2 – The performance report (Performance Analysis)

1.2.1 – Measuring performance

1.2.1.1 – Contractual and local targets

We have NHS England targets, NHS Standard contract requirements, locally agreed performance and quality measures and plans with our local health system partners (referred to in this section as targets and measures). We produce Quality, Performance and Workforce Reports for our Executive Team and Heads of Services. The Performance Report accompanies the Chief Operating Officer Report which is presented to our Board of Directors for review on a bi-monthly basis and includes the requirements for monitoring performance of national targets and standards, as well as contractual and local metrics and performance against plans. The Quality and Workforce Reports are shared with and discussed by our Board sub-committees to provide challenge, insight, and assurance.

We have in place a quality, delivery and performance framework that delivers reporting for our team and service managers, as well as Heads of Services. Dashboards and reports are used to promote discussion and challenge in team and service quality, delivery and performance meetings and operational delivery groups. We also have a reporting schedule to submit performance and quality information to our commissioners.

As might be expected with the significant challenges the Trust has faced in 2024/25, several services have consequentially had variable performance. Throughout this period our staff have worked flexibly to support our shared aim of continuing to care for our service users, providing care even when service provision was temporarily scaled back to allow staff to be redeployed to other services. All our care and support services are vitally important to people, and we have aimed, wherever possible, to deliver the care and support needed including redeploying staff where necessary.

Work has continued to understand the underlying data contributing to several of our contractual measures, to help services better understand issues with flow, capacity and demand. We remain committed to delivering care in the most appropriate, individualised and clinically effective way within the constraints we have been faced with. In 2024/25, we have further expanded the dashboards within CareDirector and made the most of interoperability opportunities to provide real time analytics from within CareDirector and our business intelligence (BI) tool, Echo. Work has continued to triangulate data from other sources, and we continue to support system colleagues to understand national data flows and utilise these for reporting – reducing the burden across the care system.

Our programme of data quality audits continued in 2024/25, the findings for these audits were presented back to operational management meetings, information governance meetings and to individual services to provide oversight and assurance of reporting. Whilst we have been informed that our contract for CareDirector will not be renewed, we continue to make improvements to where we can to ensure that data quality issues are resolved as close to the point of data entry as possible and, crucially, using this data to help services understand more about the people who access their services, supporting the Trust’s Improving Health Equity Strategic Plan.

We continue to monitor and work to improve against our contractual and local targets. The table below sets out our performance during 2024/25.

Table 1.2A – Our contractual and local targets
Our contractual and local targets

Leeds Place

Our contractual and local targets Target 2024/25
Q1		 2024/25
Q2		 2024/25
Q3		 2024/25
Q4
Timely access to a mental health assessment under Section 136 (target within three hours) No target 14.7% 8.7% 14.5% 24.7%
Crisis and Intensive Support – Timely access to crisis assessment (face to face within four hours of referral) 90.0% 73.5% 52.5% 69.6% 58.7%
Crisis and Intensive Support – Length of stay on caseload (% less than six weeks) 70.0% 87.2% 85.2% 89.7% 86.3%
Crisis and Intensive Support – Frequency of contact (seen or visited five times in first week) 50.0% 42.4% 38.3% 32.7% 30.5%
Crisis and Intensive Support – Facilitated early discharge No target 12.2% 15.3% 9.1% 9.3%
Timely commencement of a mental health assessment by the Acute Liaison Psychiatry Team in the Leeds Teaching Hospitals Trust Emergency Department (one hour) No target 76.6% 76.9% 65.3% 60.1%
Timely access to a mental health assessment by the Trust’s Liaison Psychiatry In-reach Service (24 hours) 90.0% 79.3% 79.9% 80.9% 79.9%
Bed Occupancy rates for Acute Adult Inpatient Services 94.0% 99.3% 99.8% 99.7% 99.6%
Percentage starting Leeds Autism Diagnostic Service assessment within 13 weeks No target 38.8% 34.6% 42.2% 38.5%
Perinatal Community Did Not Attend Rate No target 8.4% 10.8% 8.7% 9.1%
Perinatal Community – Timely access (less than two weeks) for routine referrals 85.0% 92.8% 94.7% 94.5% 90.6%
Perinatal Community – Timely access (less than 48hrs wait) for urgent referrals No target 80.0% 88.0% 87.5% 86.4%
Three Day Follow Up – Clinical Commissioning Group Commissioned Services 80.0% 85.3% 80.2% 81.4% 82.8%
Waiting times Access to Memory Services; Referral to first face to face contact within eight weeks 70.0% 78.1% 76.8% 79.2% 72.5%
Memory Services – Time from Referral to Diagnosis within 12 weeks 50.0% 50.3% 59.4% 62.6% 53.8%
Waiting times for Community Mental Health Teams first contact within 15 days 80.0% 81.7% 80.6% 74.0% 74.7%
Percentage of Community Learning Disability Team referrals seen within four weeks of receipt of referral 90.0% 70.2% 66.1% 73.6% 67.4%
Cardio Metabolic Assessment (current severe mental illness inpatients) 80.0% 80.2% 72.2% 70.0% 61.5%
Cardio Metabolic Assessment (Early Intervention in Psychosis Service) 80.0% 78.1% 82.9% 61.4% 44.0%
Percentage of people discharged to primary care (Early Intervention in Psychosis Service) No target 59.2% 54.7% 59.3% 52.1%

NHS England

Our contractual and local targets Target 2024/25
Q1		 2024/25
Q2		 2024/25
Q3		 2024/25
Q4
Gender Identity Service – Waiting List No target 5,935 6,143 6,310 6,501
Perinatal Community – Number of distinct women seen in rolling 12 months (Leeds Clinical Commissioning Group only) 930 1,008 1,020 1,034 984
Children and Young People’s Mental Health Service Inpatients – Assessed within seven days of admission (Health of the Nation Outcome Scales for Children and Adolescents / Goals Based Outcomes) 100.0% 100.0% 100.0% 86.7% 61.1%

Other reported indicators

Our contractual and local targets Target 2024/25
Q1		 2024/25
Q2		 2024/25
Q3		 2024/25
Q4
Appraisals 85.0% 85.0% 85.6% 81.9% 81.9%
Clinical Supervision 85.0% 73.1% 74.1% 70.2% 70.5%
Sickness Absence Rate 5.0% 6.0% 5.9% 5.9% 5.9%
Staff Turnover 10.0% 7.9% 8.2% 7.8% 8.5%
Healthcare Associated Infections – Clostridioides difficile 0 0 0 0 0
Healthcare Associated Infections – Methicillin-resistant Staphylococcus aureus 0 0 0 0 0
Delayed Transfers of Care No target 13.1% 19.6% 17.1% 19.9%
Data Completeness – NHS Number No target 99.3% 99.3% 99.3% 99.7%
Data Completeness – Ethnicity No target 81.6% 81.2% 81.8% 81.7%
Data Completeness – Sexual Orientation No target 47.5% 46.8% 47.6% 46.4%

System oversight framework and standard NHS contract

Our contractual and local targets Target 2024/25
Q1		 2024/25
Q2		 2024/25
Q3		 2024/25
Q4
Three Day Follow Up – Trust wide services 80.0% 84.7% 80.3% 81.1% 82.2%
Data Quality Maturity Index (Mental Health Services Data Set) 95.0% 88.0% 91.1% 90.8% Data Quality Maturity Index is published by NHS England three months in arrears, therefore, an updated Q4 position cannot be provided.
Early Intervention in Psychosis – % waiting less than two weeks for a National Institute for Health and Care Excellence (NICE) recommended package of care 60.0% 46.2% 64.3% 39.3% 34.3%
Never Events 0 0 0 0 0
Number of Incidents No target 3,691 3,870 3,594 3,756
Inappropriate out-of-area placements for adult mental health services (number of bed days) No target 2,854 1,641 1,832 1,937

1.2.2 – Financial performance

1.2.2.1 – Overview

The overall good financial performance and management of the Trust’s resources was maintained in 2024/25. Since the introduction of the Health and Care Act 2022 in 2022/23, overall performance is now monitored at a system level. Through a framework of collaboration and partnership working in Leeds Place and the wider West Yorkshire system, the Trust achieved it’s NHS adjusted financial position in year and contributed to the West Yorkshire system delivering it’s planned revenue break-even position. Capital expenditure limits are now also set at a system level, which the West Yorkshire system then delegated to providers. The Trust delivered a £13.4 million (m) programme in year, due to the capital limit in place, expenditure was focussed on core agreed priorities.

The national approach for 2024/25 required each system to develop a whole system revenue finance plan based on organisational run rate plans. This process allowed national analysis/scrutiny of the changes in organisations year on year expenditure by comparing prior year outturn with the following years plan. This approach is also important to the triangulation with workforce and activity returns at a national level.

The Trust has seven Private Finance Initiative (PFI) properties, all NHS organisations with PFI properties were impacted by an accounting treatment change in 2024/25, International Financial Reporting Standard (IFRS) 16. As a result of this technical change the expenditure in the Income & Expenditure (I&E) is notionally reduced, this technical adjustment is then removed for reporting purposes to NHS England together with impairments and peppercorn lease expenditure in the year, resulting in the £1.2m reported position to NHS England.

Table 1.2B – Adjusted Financial Performance
Adjusted financial performance Year ended 31 March 2025 (£000)
I&E surplus reported 4,356
Add back all I&E impairments and peppercorn leases 508
PFI revenue costs (remove IFRS 16, add UK GAAP basis) net (3,682)
Adjusted financial performance surplus / (deficit) 1,182

For the Trust to achieve it’s revenue adjusted £1m surplus financial plan in year, we needed to reduce run-rate/expenditure in year by £16.9m compared to the 2023/24 outturn position. It was agreed that focus would be on five key areas to deliver the plan, All the measures were in recognition of the need to balance patient safety, experience and outcomes, whilst providing the organisation with headroom to recover its financial position. The five areas were, reducing pay, reducing the reliance of agency & locums, rostering review, non-pay controls and reducing out of area placements (where service users cannot receive inpatient treatment locally, due to bed capacity).

NHS England set systems the target of not spending more than 3% of total staff expenditure on agency costs. Therefore, the aim for the Trust was ensuring sufficient safe staffing cover was maintained to reduce agency and locum expenditure with significant levels of vacancies within the Trust. Overall, the system did stay within this 3% target, however the Trust’s agency expenditure was 4% of total Trust pay expenditure even though Trust agency reduced £2.8m compared to 2023/24. The use of out of area placements decreased for working age adults in year and the Trust continued to make good progress in reducing complex rehabilitation placements in year. The Trust also incurred significant cost pressures due to inflationary price increases across most non-pay budgets within the financial year, specifically utilities and food prices.

1.2.2.2 – The Statement of comprehensive income (year-on-year)

The statement of comprehensive income shows a surplus of £4.4m for the year ended 31 March 2025 (compared to a deficit of £0.5 million in the previous year). However, this includes technical adjustments of £3.3m due to fixed asset impairments and the impact of changes to international financial reporting standards in relation to the accounting treatment for our PFI expenditure. Excluding these technical items (which are not included in system control totals) the Trust delivered a £1.2m surplus. It is a very positive result for the Trust to be able to deliver a surplus despite the ongoing challenges. This reflects the fact that the Trust had all the available resources required and had some non-recurrent benefit due to unplanned income including that from commercial activities and some service development slippage.

1.2.2.2.1 – Operating income

Trust income for the year increased to £277.4m (£256.9m in 2023/24). This is an overall increase of 8%. The main change reflects the impact of inflation, and service development funding reflecting the Mental Health Investment Standard and long-term plan commitments. All payments to NHS trusts for clinical services were maintained on a block basis throughout the year. There were some changes in other non-clinical income for commercial activities. In addition, finance income of £6m (£6.4m in 2023/24) was received in the year. This is interest received as a consequence of the Trust having high cash balances and thus benefiting from high interest rates calculated on our deposits, however as interest rates are decreasing this non-recurrent income will not be able to be relied upon in future years.

1.2.2.2.2 – Operating expenses

The total operating expenses for the year was £276.5m (£258.6m in 2023/24), which is a net increase of 7%. Staff costs are the Trusts single largest operating expense, and this increased by 11%. This included all confirmed aspects of the 2024/25 pay award and the increase in employer pension contributions (3.1%), accounted for in year and there were also some small service development initiatives. There continues to be significant pressures due to the continuing level of agency expenditure in year of £8.4m (£11.2m in 2023/24). Although this reduced in year, it remains a significant pressure that reflects workforce challenges mainly in recruiting to key medical roles. Over 70% of total agency spend was in relation to medical locum expenditure, as hard to recruit to consultant roles was a key challenge throughout the year. Recruitment and retention is a high priority focus area in the Trust’s People Plan.

1.2.2.3 – Capital expenditure

All ICS’s must work within a defined capital allocation that is then devolved down to provider organisations, with additional funding allocated for specific purposes. Capital expenditure planning continued to be affected by inflation and capacity. Total capital investment for the year was £13.4m (£6.1m in 2023/24). The Trust’s significant investment in year included frontline digitisation, the perinatal scheme at the Mount and the high intensity scheme at Parkside Lodge. These schemes continue into 2025/26. A contribution from public dividend capital of £8.2m was received in year in relation to our capital programme. In addition to the major projects, the balance of expenditure was spent on other operational priorities, including IT infrastructure and backlog maintenance of the estate.

1.2.2.4 – The statement of financial position

The summary of the Trust’s overall value shows a net increase in taxpayers’ equity of £13.7m to £135.1m as at 31 March 2025. This reflects the surplus generated in the year, the annual revaluation and the public dividend capital received in year. Working capital (current assets less current liabilities) reduced £1.5m in year, within this net cash increased £7m and receivables increased £1.3m, offset by an increase in payables, provisions and other liabilities. The surplus cash held at the end of the year was deposited with the Government Banking Service (GBS).

It is Trust policy to deposit any temporary surpluses in cash in low-risk deposit accounts with either United Kingdom commercial clearing banks or the HM National Loans Fund, when interest rates are more beneficial than GBS.

1.2.2.5 – Future financial outlook and risks

It is clear from the recent news that the financial environment in 2025/26 will be significantly challenging within the NHS and there will be many changes in year that will no doubt lead to some instability in year. NHS England is being taken back into direct government and in planning guidance there has also been greater emphasis on increasing productivity to pre-pandemic levels and all NHS organisations await the soon to be released NHS 10 year plan.

The West Yorkshire Health and Care Partnership, like most systems, is entering 2025/26 with significant overall financial risk, which may manifest differentially across organisations and places, but with a shared obligation to achieve targets. The system capital allocation constrains programmes and the funding formula to produce this allocation brings additional complexities. The Trust has a reduced capital resource envelope for 2025/26 which means prioritisation is key and difficult decisions on which projects to proceed with will have to be made, based on relative risk. There is also an efficiency challenge of £18.5m in 2025/26 that means robust, feasible plans are essential to ensure that the Trust remains financially sustainable. Progress has been made to meet this efficiency challenge and embed good governance in the process of identifying and delivering recurrent savings.

The Trust remains challenged in terms of workforce, but this is also an opportunity to think about skills and roles, supported by a robust People Plan to underpin the work needed. Capital investment priorities and requirements will become more challenging in the medium term with reduced capital allocations. The Trust remains in a solid financial position and is fully cognisant of the risks and challenges it faces, which are not dissimilar to the scale of challenge facing the NHS overall. The current robust standing will help us to move forward positively to meet these challenges.

1.2.2.6 – Our exposure to financial risks

Price risk
The Trust has a relatively low exposure to price risk, although this is becoming more unpredictable. Salaries continue to be the single biggest component of costs and for 2025/26 financial plans reflect a nationally assumed 2.8% pay award. If a different amount is agreed, the majority of this increase will be covered by additional central resource, however, as NHS England uses a national formula for this, mental health providers, due to having a greater percentage of staff costs, often end up being disadvantaged when compared to Acute providers. With regard to non-pay, plans assume a level to the projected rate of increase in the consumer price index, and volatility beyond this can be managed in-year as the biggest component is fixed in terms of known PFI inflation agreed.

Income assumptions are set through the financial planning framework arrangements for the NHS, as mandated by the Department of Health and Social Care. The majority of income is received on a ‘block contract’ basis rather than ‘pay as you go’ and it is therefore highly unlikely that a significant part of our income will change quickly.

Credit risk
This is minimal as the majority of our customers are public sector organisations, in particular NHS organisations.

Liquidity risk
Liquidity risk is felt to be low. This is because operating costs are incurred primarily through legally binding contracts for services provided to clinical commissioning groups and NHS England, which in turn are financed from money received from Parliament. Assumptions about future income have been revised to take into account the new market conditions.

Cash-flow risk
The main sources of income and expenditure are extremely predictable. The Trust is forecast to retain significant cash and other liquidity resources for the foreseeable future. Cash-flow risk is therefore felt to be low due to the adequate level of cash reserves; and the Trust not having sought a working capital loan facility because we have sufficient working capital. The Trust has modified its capital expenditure plans and has a robust approach to investment appraisal including risk issues.

1.2.3 – Corporate social responsibility

1.2.3.1 – Human rights

Our Trust recognises the importance of the Human Rights Act as foundation legislation and we ensure that we protect, respect and fulfil peoples’ human rights in everything we do. Minimum standards are set out within our Equality, Diversity and Human Rights Procedure and adherence to these standards and principles is monitored through our governance structure. The Trust has completed a significant training programme with the British Institute of Human Rights (BIHR) with awareness training for 300 staff and an in-depth practice leads course for 40 staff. We have developed a FAIR decision-making framework, to ensure that due regard is given to people’s human rights when any restrictive intervention is considered and provided support for staff with their decision making through the Human Rights Community of Practice. We have secured funding to repeat the awareness training for a further 300 staff and are working with the BIHR to produce an LYPFT human rights resource tool.

1.2.3.2  Sustainability report

1.2.3.2.1 Introduction

In October 2020, the NHS became the world’s first health service to commit to reaching net zero carbon emissions, in response to the profound and growing threat to health posed by climate change. The Trust has committed to driving sustainability through the launch of its Green Plan in January 2022 and the development of a Sustainability Team within the Estates and Facilities directorate.

Two targets are outlined in NHS England’s ‘’Delivering a ‘Net Zero’ National Health Service’’ report:

  • The NHS Carbon Footprint: for the emissions we control directly, reach net zero by 2040.
  • The NHS Carbon Footprint Plus: for the emissions we can influence, reach net zero by 2045.

These targets are monitored through the Green Plan, quarterly Greener NHS Data Collections and the nationally calculated carbon footprint by NHS England.

1.2.3.2.2 The Trust’s Green Plan

The Green Plan was first launched in January 2022 and has recently been updated to cover the 2025 – 2028 period. The plan sets out our environmental sustainability strategy with actions to be achieved over the next three years and outlines the governance arrangements to keep the plan on track. We have also calculated a new baseline year for our carbon footprint emissions including scopes 1, 2 and 3 for 2022/23 to give us an understanding of baseline emissions post-pandemic.
The updated Green Plan was approved by the Board in January 2025 and steps are now being taken to embed the plan further within the Trust’s processes and services.

1.2.3.2.2.1 Our Green Plan Vision

The vision of the Trust is:

  • We achieve net zero carbon ahead of schedule and are seen as an exemplar mental health trust.
  • All staff feel passionate about helping the Trust to become net zero carbon.
  • All staff and service users feel involved and valued in the process.
  • LYPFT embeds environmental commitments as a thread throughout all business activities.
  • We reach out to our local partners and work collaboratively to share best practice and where possible, to collectively bid for investment in transforming our estate to net zero carbon.
  • We are working to be at the forefront of supporting our communities to be prepared for the low to zero carbon future ahead through implementing effective climate mitigation and adaptation measures.
  • We adopt a collaborative approach throughout the organisation and beyond, by supporting education and therapeutic involvement with our environment, creating informed networks for enabling safer, healthier, and more sustainable outcomes, both for our staff and especially for our service users.
  • We foster a rewarding and supportive place to work where staff can achieve their personal and professional goals with regards to sustainability, providing a supportive and fair environment in which to deliver fulfilling work and great care.
1.2.3.2.2.2 Trust Priorities

Our Green Plan focuses on nine workstreams ranging from procurement to medicines, travel and adaptation, in accordance with the Greener NHS Green Plan Guidance and outlines the Trust’s sustainability priorities for the next three years. A key priority for the 2025 – 2028 period in line with Greener NHS carbon targets is a focus on the carbon emissions from our owned estate, looking at ways to improve energy efficiency, staff and service user comfort, installation of renewables, reducing waste and improving our green spaces.

Priorities for 2025/26 include embedding the updated Green Plan across the Trust, increasing staff and clinical engagement, providing staff training, improving active travel facilities and electric vehicle charging, and understand our climate change risk and how we need to adapt.

1.2.3.2.3 Our Performance

Whilst hybrid working is very much still in place across the Trust, there has been a ‘return to normal’ following the Covid-19 pandemic in the last couple of years. As such, our energy consumption and waste production now represent business as usual levels.

1.2.3.2.3.1 Energy Use

Total energy use has continued to decrease across the owned & leased estate when compared to the previous year’s combined consumption, Gas use has reduced by 8.09%. Electricity use has shown a marginal increase of 1.85%. The additional electricity use is attributed to St Mary’s Hospital, Red Kite View, and St Mary’s House, and is likely due to slight increases in occupancy levels, particularly as Trust Headquarters has now fully migrated to St Mary’s House.

NHS Property Services (NHSPS) energy data is now being provided in full where in previous years we have had only partial data. This will allow us to draw year-on-year comparisons. Total energy use across the PFI estate has decreased slightly (2%) when compared to the previous years combined consumption. Gas use has reduced by 0.35%. Electricity use has reduced by 6.91%.

Mitigation activities reported in the 2023/24 annual report, such as the roll-out of high efficiency lighting (LEDs), increasing solar panel arrays, improved contract management, and improved data monitoring via sub-metering, continue to progress.

Throughout the year the Trust has continued to procure 50% renewably generated electricity for its owned and leased estate. As of April 2025, the Trust will transition to the new NHS England and Crown Commercial Services Energy Framework which is expected to provide cost savings, access to funding and energy saving opportunities, improved energy management and a return to 100% renewably generated electricity. The NHSPS estate continues to procure 100% renewably generated electricity leased estate use renewable electricity.

Table 1.2C – Electricity and gas consumption

Owned and Leased Sites 2021/22 2022/23 2023/24 2024/25
Electricity Consumption (kWh) 1,364,152 1,484,021 1,488,832 1,516,441
Natural Gas Consumption (kWh) 2,835,187 3,683,306 3,119,721 2,940,994
PFI Sites 2021/22 2022/23 2023/24 2024/25
Electricity Consumption (kWh) 2,245,777 2,016,814 1,994,607 1,856,676
Natural Gas Consumption (kWh) 5,658,222 5,770,878 5,819,818 5,799,251
NHSPS Sites 2021/22 2022/23 2023/24 2024/25
Electricity Consumption (kWh) 270,976 806,263 851,027 660,358
Natural Gas Consumption (kWh) 449,033 420,552 1,027,933 671,165

Please note: the figures for 2023/2024 are all estimated figures updated.
All Electricity and Natural Gas consumption for March 2025 is based on estimated figures. Data for quarter four of 2024/25 is not provided by NHSPS. Only partial data is available for 2021/22 and 2022/23 from NHSPS.

1.2.3.2.3.2 Waste
Total clinical waste volumes have decreased by 10% compared to the previous year’s updated volumes. The Trust is continuing to implement its new internal bin roll-out, including new signage, bin rationalisation and the removal of communal personal protective equipment (PPE) bins, following the mandatory face masks lift. These initiatives are having an impact on improved clinical waste segregation, thus reducing volumes of both offensive and infectious waste.

Total non-clinical waste volumes have increased this year compared to the previous year’s volumes; further investigation is required to understand the causes. The Trust successfully launched its catering services food waste collections in the summer, which has expanded food waste collections to four sites. Over the coming year it is hoped food waste collections will be expanded further to include non-catering services food waste.

The Trust continues to meet and exceed the NHS Clinical Waste Strategy target to achieve a 60/20/20 split for offensive, alternative treatment and incinerated clinical waste, respectively. As part of our Waste Management Improvement Plan, our aim is to further reduce energy intensive waste streams and expand our non-clinical waste streams to increase recycling, recovery, and reuse, in line with the Simpler Recycling Regulations. A new Waste Management Policy and Procedural Manual continues to be finalised which will be aligned with the recently updated Health Technical Memorandum 07-01: Safe & Sustainable Management of Healthcare Waste and the NHS Clinical Waste Strategy. Over the coming year, The Trust is planning to re-introduce an internal waste auditing programme and provide staff training to further improve waste reduction and minimisation.

Table 1.2D – Waste Volumes

All sites 2021/22 2022/23 2023/24 2024/25
Incineration Clinical Waste (tonnes) 9.55 15.16 7.33 6.97
Alternative Treatment Clinical Waste (tonnes) 22.23 31.34 17.08 14.54
Energy from Waste Offensive Waste (tonnes) 205.97 110.19 144.83 130.61

Please note: The figures for 2023/2024 for all sites are estimates updated.

Owned and Leased & NHSPS Sites 2021/22 2022/23 2023/24 2024/25
Landfill Waste (tonnes) 2.80 1.18 0.20 0
Energy From Waste (tonnes) 36.12 54.56 65.87 71.52
Anaerobic Digestion Food Waste (tonnes) 0.0 0.25 2.37 2.18
Recycled Waste (tonnes) 168.23 90.61 29.84 36.19
PFI Sites 2021/22 2022/23 2023/24 2024/25
Landfill Waste (tonnes) No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider
Energy From Waste (tonnes) No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider
Anaerobic Digestion Food Waste (tonnes) No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider
Recycled Waste (tonnes) No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider No data provided by PFI provider

All waste data is calculated using average full bin weight estimates, except for 2024/25 food waste which is dynamically weighed at source.

Clinical waste data for March 2025 is based on estimates.

Partial Food Waste data from July 2024 – March 2025 due to newly implemented service.
1.2.3.2.3.3 – CO2 Emissions
Carbon emissions from both electricity and gas have reduced compared to last year by a total of 3.6%. This is likely due to reductions in consumption of energy and a minor decrease in the carbon intensity of the national electricity grid.
Table 1.2E – CO2 Emissions

 

CO2 Emissions 2021/22 2022/23 2023/24 2024/25
CO2 from Electricity (tonnes) 953 1,050 975 909
CO2 from Gas (tonnes) 1,575 1,492 1,754 1,721
Total 2,528 2,543 2,729 2,630

Please note: the figures for 2023/2024 are all estimated figures updated.

The Trust’s CO2 emissions are also affected by those under scope three, including:

  • waste volumes
  • water use
  • travel and commuting
  • working from home
  • the goods and services we purchase and use.

1.2.3.2.3.4 – Taskforce for Climate-related Financial Disclosures (TCFD)
NHS England’s NHS Foundation Trust Annual Reporting Manual has adopted a phased approach to incorporating the TCFD recommended disclosures as part of sustainability annual reporting requirements for NHS bodies, stemming from HM Treasury’s TCFD aligned disclosure guidance for public sector annual reports. TCFD recommended disclosures, as interpreted and adapted for the public sector by the HM Treasury TCFD aligned disclosure application guidance, will be implemented in sustainability reporting requirements on a phased basis up to the 2025/26 financial year. Local NHS bodies are not required to disclose scope 1, 2 and 3 greenhouse gas emissions under TCFD requirements as these are computed nationally by NHS England.

The phased approach incorporates the disclosure requirements of the governance, risk management and metrics and targets pillars for 2024/25. These disclosures are provided below with appropriate cross referencing to relevant information elsewhere in the annual report and in other external publications such as the Green Plan, where compliance is currently achieved. Where further work is needed, especially for the risk, and metrics and targets pillar the disclosure requirements have been provided on an explain basis.

Governance Pillar

The Board has oversight of climate-related issues via the Green Steering Group which is the quarterly governance group for the work of the Green Plan, this group is chaired by our Chief Financial Officer (CFO), providing executive leadership on sustainability. We also have a Non-Executive Director Champion for sustainability. Progress on the Green Plan and sustainability work is reported annually to the Board of Directors and biannually to the Finance and Performance Committee. The Green Steering Group includes representatives from Procurement, Finance, Communications, and Estates and Facilities, alongside the Sustainability Team.

The Green Plan is the formal organisational plan which outlines the targets and actions agreed to reduce the Trust’s impact on climate change. This plan is a board approved document and covers a three-year period (2025 – 2028). The plan includes the Trust’s baseline carbon footprint, key KPIs and an action plan for improving sustainability of the Trust. Following adoption of the updated Green Plan, the Board will be able to monitor progress against the Green Plan through quarterly updates.

The Board does not currently consider climate-related issues when reviewing other organisational plans or as part of key decision making across the Trust. As further work is undertaken on climate change risk and adaptation, and the Trust develops a greater understanding of capital costs for decarbonisation, the Board will receive information to consider in the future.

Sustainability and climate-related responsibilities are assigned to the Estates and Facilities Directorate and managed by the Sustainability Team which includes a Sustainability Project Manager and a Waste and Sustainability Manager. The Green Steering Group acts as the governing committee and reports to the Finance and Performance Committee, which then reports to the Board of Directors. The Sustainability Team attend the estates and facilities operational meetings, where sustainability is a standing agenda item.

Risk Management Pillar

The Emergency Preparedness, Resilience and Response (EPRR) Team has assessed climate-related risks such as overheating, flooding, extreme weather events and utilities failure and included these on the EPRR Risk Register. This register is closely linked with the Trust’s Corporate Risk Register (DATIX) as well as national and regional risk registers. This ensures that any climate change related risks can be monitored at a trustwide level. There are currently two climate related risks on the Trust’s Corporate Risk Register, these are ‘New and Emerging Pandemics’ and ‘Heatwave and Heat Incidents’.

The EPRR Risk Management Procedure outlines how risks are identified, assessed, reviewed, and escalated from the EPRR Risk Register to the Trust’s Corporate Risk Register, external regional risk registers or to Board. Risk management follows a five-step process; risk identification, evaluation, control, monitor and review.

It is proposed that the Trust’s Sustainability Team will conduct a climate change risk assessment and develop an adaptation plan in collaboration with the EPRR Team to identify, capture and manage the full range of climate-related risks to the Trust, especially those with health related impacts, such as those listed in Table A1.1 in Annex A of the HM Treasury application guidance.

Metrics and target pillar

Whilst we do not have any historical trends of climate related metrics or KPIs, apart from the data reported earlier in this section, and national data collections e.g. Estates Return Information Collection (ERIC) Returns, we plan to introduce new KPIs within our updated Green Plan to offer more specific measurement of progress against sustainability targets and the NHS net zero goal. These KPIs can be found detailed in our Green Plan 2025 – 2028.

Climate-related targets are included within the Green Plan and are in line with the national NHS targets for meeting net zero emissions set out in the ‘Delivering a Net Zero National Health Service’ report.

1.2.3.2.3.5 – Conclusion

The Sustainability Team continue to develop strategic plans for improving the environmental impacts of the Trust, increasing sustainable behaviours and practices, and reducing carbon emissions. Ongoing improvements to waste management, energy efficiency, renewable energy installations, EV Charging, active travel facilities and engagement with staff are planned for 2025/26.

1.2.4 – Anti-bribery culture

We have a zero-tolerance approach to bribery and the Board has in place an Anti-Bribery and Fraud Policy which is available to staff on Staffnet. Staff are reminded of their responsibilities under the procedure and how to access this on a regular basis. Counter-fraud services are provided by NHS Audit Yorkshire who carry out proactive and, where necessary, reactive work in relation to bribery. The Local Counter Fraud Specialist makes a report to each meeting of the Audit Committee to provide an update on progress with their work. In 2024/25 there were no instances of bribery identified within the Trust.

1.2.5 – Health inequalities

Health equity is at the core of what we do as a Trust as we serve a diverse population and a patient group at high risk of poor health outcomes. We recognise that each person at the Trust has a part to play in supporting the delivery of health equity, with this in mind the Trust has developed an Improving Health Equity Strategic Plan 2025-2029. Read our Improving Health Equity Strategic Plan.

This marks a significant step forward in our commitment to working to address the inequity in health outcomes within our communities. We know tackling health inequality is a complex issue and will require co-ordinated system-level solutions, by working in partnership with local authorities, integrated care systems and voluntary, community and social enterprise sector organisations. Collaborative working is fundamentally embedded across the work of our Trust to enable us to deliver on this agenda.

Our Improving Health Equity Strategic Plan largely focuses on improving equity in access, experience and outcomes within healthcare. We are particularly concentrating on the following groups:

  1. The systematic, unfair and avoidable differences in health between those with learning disability, neurodiversity, severe and enduring mental illness, and those without.
  1. Tackling racial health inequity within mental health services which have been evidenced to be extensive and persistent.
  1. Intersectionality: People at exceptionally high risk of poor health outcomes because they are a member of multiple groups and experience compounding disadvantage for example those with a severe mental illness and from a racialised community and who also live in a deprived community.
  1. Our service users who experience deprivation, with a particular focus on our service users living in the 10% most deprived communities nationally.

We carried out widespread engagement to understand and shape the creation of a new strategic approach to improving health equity for our Trust. Below is a summary of the engagement that was undertaken:

  • Met with approximately 500 people, either virtually or face to face
  • Hosted an open access webinar to approximately 120 attendees
  • Presented at clinical governance meetings, strategic internal and partnership meetings, the Trust’s all staff huddle, and staff networks, including the Workforce Race Equality Network, the Disability and Wellness Network and the Rainbow Alliance
  • Presented to the Trust’s Board of Directors, Council of Governors and the Tackling Health Inequalities Group
  • Engaged with key system partners, including Leeds City Council’s Public Health Team and other system equality leads
  • Presented at our Service User Network.

Alongside this new strategic approach, in 2024/25 our services continued to identify their health inequality priorities, informed by data, intelligence and learning through Covid-19. Steered by the leadership teams in each of our services, these priorities identify specific gaps in access, inclusion, and experience in the communities of people served by these specialities.

We have ensured that the foundational element in the delivery of our Quality Strategic Plan is to embed our quality model based on the STEEEP framework, which stands for Safe, Timely, Effective, Efficient, Equitable, and Patient-centred care. Equity is a cornerstone of this work and as a Trust we are focusing on specific coordinated action through this Plan. We will work closely with quality, clinical and operational leads to implement this strategic plan ensuring we make the best use of our resources with focus.

We have continued to strengthen our work on inclusion through designated Inclusion Lead posts in our Perinatal Mental Health Service, Community Services, Crisis Services, and Eating Disorder Services. The services demonstrated a significant benefit from having dedicated resource working within their teams specifically to ensure that the Trust’s inclusion ambitions are achieved. There has been significant progress made resulting in the development of schemes and campaigns to proactively reach into communities of people who are under-represented in our services, such as:

  • Remembering what’s forgotten:

A programme and exhibition which champions community and lived experience narratives to tackle the overrepresentation of Black and South Asian men detained under the Mental Health Act in Leeds.

  • The Diverse Mums’ Group:

A maternal Journal Course using creative mediums to overcome social isolation, improve mental health, increase uptake of mental health support and provide feedback on services from underserved cohorts.

  • In BIG letters:

A co-design project to respond to people with learning disabilities asking for medication labels and information that better meets their needs and improves patient safety.

  • Sikh Mental Health Workshop:

Collaborating with community partners to provide culturally tailored workshops to raise awareness of perinatal mental health.

In line with the Improving Health Equity Strategic Plan, we have continued to focus on the areas identified by NHS England’s requirements on health inequalities including:

1.2.5.1 – Patient Carer Race Equality Framework

The Patient and Carer Race Equality Framework (PCREF) is the first ever anti-racism framework from NHS England. We are proud to share that the Trust was selected to be one of the national early implementer sites. This work brings ground-breaking change to our sector and promotes a whole new dimension of co-production, where individuals and communities are at the heart of the design and implementation of the services they need.

This work enables us to focus our efforts in our journey to becoming an actively anti-racist organisation by ensuring that we are responsible for co-producing and implementing concrete actions to improve racial equity within our services. Below is a summary of the Trust’s PCREF progress in 2024/25:

  • Assigned an executive PCREF Lead at Trust Board level accountable for delivery and oversight
  • Agreed governance structures for delivery and oversight
  • Established a PCREF Project Group
  • Partnered with NHSE’s ‘Advancing Mental Health Equalities Taskforce’ as a PCREF early implementor site
  • Developed draft terms of reference and recruited four lived experienced community members to be members a new the Partnership Group.
  • Partnered with West Yorkshire Integrated Care Board (ICB) and engaged a broad range of stakeholders and discussed their membership of the partnership group.
  • We have designed and developed an Equity Data Dashboard to review measures by a wide range of equity variables, including ethnicity. We started by including equity measures that we have a statutory obligation report on such as detention rates and restrictive practises.
  • Developed training on improving quality of data collection around protected characteristics.

We continue to work with West Yorkshire mental health collaborative, who are supporting PCREF from a regional perspective as we collaborate in a series of listening sessions with patients, carers and system partners to help inform our plans on what will make the difference to racial equity for our populations.

1.2.5.2 – Equality and Health Inequality Impact Assessments (EHIA)

As part of the coordinating work in our new Improving Health Equity Strategic Plan, the Board of Directors requested a review of our Equality and Health Inequality Assessment policy and procedure. We have established a working group to review how the Trust assesses the potential impact of a policy, practice or programme of work on groups with protected characteristics, and whether, and to what extent our equality and health inequalities duties are affected and facilitate legal compliance. This new group is carrying out a full review of several important principles, particularly what due regard means for us as an organisation, building new supporting guidance and policy for dissemination across the Trust.

1.2.5.3 – Equality Delivery System (EDS)

The Trust has contributed to a systemwide approach to improving equity within care through our statutory duties under the Equality Delivery System. This work focuses on assessment of equity within services and subsequent improvement activities.

In 2024/25, the EDS provided an opportunity to collaborate with place partners, Leeds ICB and NHS providers to gather relevant Palliative and End of Life Care evidence for Domain 1.

At LYPFT the Older People Services, Dementia and End of Life Care were audited. Evidence relating to Domains 2 and 3 was primarily obtained from the Health and Wellbeing Team and the Corporate Governance Team. A detailed scorecard is provided by NHS England for each of the 11 outcomes, which leads to a score for each domain.

The Trust’s overall organisational rating summary is ‘Developing’:

  • Domain 1: Commissioned or provided services overall rating: 7 (out of a possible 12)
  • Domain 2: Workforce health and well-being overall rating: 6 (out of a possible 12)
  • Domain 3: Inclusive leadership overall rating 3 (out of a possible 9)
  • Overall Organisation Rating 16 (out of a possible 33)

1.2.5.3 – CORE20PLUS5

The CORE20PLUS5 is a framework to support the NHS tackle health inequalities. This approach is embedded at the heart of our new Improving Health Equity Strategy. CORE20 means for organisations should take a targeted approach to addressing the health concerns of the 20% most deprived communities nationally. Due to the demographics of the populations we serve, our Improving Health Equity Strategy outlines a more targeted approach to the 10% most deprived communities nationally which make up over a quarter of the population of Leeds. The ‘PLUS’ part of the framework directs us to have a focus on delivering improvements for groups at particularly high risk of inequity. We have adopted this approach within our strategic plan, focussing on those with learning disability, neurodiversity, serious mental illness, as well as minority ethnic groups and those with multiple layers of disadvantage such as those experiencing homelessness.

1.2.5.4 – Annual health checks for people with serious and enduring mental illness

We are focused on improving the physical health of our service users as part of our strategic ambition to ensure that we support and deliver access to physical health care for those most at risk of poor health and significant health inequity due to their mental health issues. Specifically, we employ physical health professionals to drive this ambition but also oversee the delivery of annual health checks whilst people are in our care. This is part of, but not the whole of our work. Additionally, as an organisation working in partnership in Leeds and the region, we influence and support this work across the health and care system. The Board of Directors monitors our performance against this standard as a matter of routine and have actively supported recovery as part of restoring our service offer post Covid-19.

1.2.5.5 – Smoking cessation

Smoking cessation is embedded across all five clinical areas within the CORE20PLUS5 framework. The Trust has a strong commitment to facilitating smoking cessation for our service users.

The Trust has adopted a robust Smoke Free Policy and has been working with all services across the Trust to embed the policy. We offer smoking cessation and support to all inpatient areas across the Trust, including maternity services on an opt out basis. The Trust offers the full range of treatments for nicotine addiction according to NICE guidelines and provides support to people who smoke throughout their admission if required. Support and smoking cessation advice is offered through innovative methods such as ward based “chill and chat groups” where information on smoking cessation is interwoven with other health advice.

The Trust also has a smoking cessation offer for staff, which includes delivery of the ‘Swap to Stop’ programme, where vapes are utilised as a quit aid.

1.2.5.6 – Protect the most vulnerable from Influenza and Covid-19

Building on the success of our vaccination delivery programme, which commenced in January 2021, we have embedded our approach and delivery model into business as usual. This means that we can support people with serious mental illness and/or learning disabilities to access the Covid-19 vaccine, and flu vaccine. Specifically, we aim to encourage and facilitate uptake and protection of vulnerable people. We focus on the direct delivery of the vaccine across inpatient wards and reach service users with serious mental illness in our community services.

1.2.5.7 – New Translation and Interpretation Service

By collaborating with partner organisations, we have secured a high-quality interpretation and translation service for the Trust which will also be more streamlined and cost-effective. This will provide better value for money while improving accessibility and equity for the diverse populations we serve across Leeds, York, and the wider regions we work in.

Through this collaboration, we are strengthening service provision by working with a broader network of qualified interpreters and translators. This will enable us to better meet the linguistic and cultural needs of our service users, helping to remove communication barriers, support person-centred care, and ensure that patients receive the right support in a timely and effective manner.

1.2.5.8 – Workforce development

  • In 2024, 182 staff received Cultural Competency and Humility training. This course is delivered to healthcare professionals to become aware of their own cultural norms, examine personal biases, stereotypes and prejudices. The training explores why inequalities exist and persist and empower services to become more culturally responsive to improve health outcomes.
  • We hosted the ‘Through My Eyes Equity Education Event’ – increasing cultural awareness in perinatal mental health and embedding best practice through listening to the patient voice. Perinatal mental health workshops were carried out with midwifery students at the University of Leeds. Both events aimed to reduce inequalities and improve maternal mental health outcomes for people from diverse communities.
  • The Trust is part of the new national programme to improve the culture of care in mental health, learning disability and autism inpatient care in England. The programme has been commissioned by NHS England and is a key element of its Quality Transformation Programme. The programme will run for two years, from April 2024 to March 2026.

The overall aim of the programme is for wards to provide safe, therapeutic and equality-focussed care in line with the ambitions of NHS England’s forthcoming co-produced Culture of Care Standards for Mental Health Inpatient Care.

  • In 2024/25 we have been working with our partners across Leeds to secure funding to develop a Health Equity Development programme to be delivered across our workforce. The Leeds Health and Care Academy will lead this work to provide a multi-level development programme over the coming two years focussed on role specific, practical actions that frontline staff and clinical managers can take to improve health equity.

1.2.5.9 – Mitigating against digital exclusion

Mitigating against digital exclusion and making sure that we meet the communication needs of people with disabilities and people with impairments or sensory loss is a legal requirement under the Accessible Information Standard.

NHS England’s 2022 review of the Accessible Information Standard found that many people continue to receive information from health and social care organisations in formats they are unable to understand and do not receive the support they need to communicate effectively. The review recommended introducing an enhanced assurance process using a set of metrics that would allow an organisation’s performance against the standard to be measured.

The Trust has been selected as a pilot area to test the new Accessible Information Standard self-assessment process before its pending release. We are currently participating in the pilot, which is being led by Healthwatch Leeds.

Initially, we have supported our Older People’s Community Mental Health Team and Memory Assessment Service through the self-assessment process. We are now scaling up this programme of work across each of our service lines, to obtain insight and identify the areas where it is possible and practical to make improvements to the accessibility of our communications.

We are working closely with management teams to guide services through the self-assessment process with the objective of acting upon identified areas for improvement as they arise.

Oversight of this programme of improvement work is led by the Trust’s Senior Communications Officer with a wide range of professionals and services within the Trust. We are committed to:

  • Overseeing the self-assessment and audit work across care services and communications touch points, i.e. referral correspondence, care services contacts, Trust website, social media channels, the Patient Advice and Liaison Service and complaints etc.
  • Researching implementation guidance and best practice (i.e. who is already doing this well and what can we learn from them?)
  • Ensuring appropriate involvement of service user and carer voice
  • Undertaking process mapping work to identify how well our systems are set up to facilitate this work (i.e. recording on CareDirector), how they could be adapted, and recommendations for improvement
  • Creating and implementing a project plan for improvement across all care services and communications touch points
  • Ensuring alignment to complimentary strategic programmes of work, including Improving Health Equity, PCREF, website accessibility project and the AccessAble implementation project led by our Estates Team
  • Developing and publishing guidance, policy and procedural documentations for care services and project stakeholders
  • Reporting progress regularly to the Nursing and Professions Council flagging risks and issues
  • Migrating the process to business as usual on completion of the project

1.2.5.10 – Improving the accessibility of our website

The Trust’s website is our digital front door to the world. In 2024/25 it was viewed around 366,000 times by 137,000 people for an average time of over two minutes and 45 seconds.

In 2024 the Trust’s Communications Team set up the Website Development Project. One of its main aims was to bring the current site into compliance with standards set by the Government Digital Service (GDS) who regulate the accessibility of public sector websites and digital apps. These regulations are in addition to our obligations to people who have a disability under the Equality Act 2010. Our aim is to bring the current site up to Web Content Accessibility Guidelines (WCAG) 2.2 AA standard by September 2025.

In January 2025 the Trust’s website was audited by the GDS. The audit highlighted several accessibility issues on our website. The audit came at a helpful point in the website development project’s critical path, as the findings supported an audit we had already commissioned that has been carried out a few months earlier by our website agency, HMA. We were able to provide assurance that the relevant in scope accessibility actions listed on their report would be completed by 31 March 2025, ahead of their deadline.

We are now engaged in a home page redesign and a site-wide audit of all content which will be completed by September 2025. As part of this, we have instigated a new approach to creating accessible content which includes a much stricter policy on uploading PDF documents to the website, as these are classified as inaccessible for people with specific communications needs.

We have also revised the accessibility statement on our website to reflect the changes made and our commitment to compliance.

View the current accessibility statement.

1.2.5.11 – Working as a system partner

In 2023 the Leeds Health and Care Partnership, which includes LYPFT, published the five-year Healthy Leeds Plan. Our work actively supports its two main goals of:

  1. Reducing preventable unplanned care utilisation across health settings; and
  2. Increasing early identification and intervention of physical and mental illnesses.

These goals are focussed on the 26% of the population in Leeds who are living in the 10% most deprived areas. 2023 also saw the publication of the Leeds Health and Wellbeing Strategy which we are actively supporting the delivery of.

We are members of the Leeds Healthcare Inequalities Oversight Group which falls within the remit of an expert advisory group and assurance function within the Leeds Health and Care Partnership. The primary purpose of the Leeds Healthcare Inequalities Oversight Group is to support and capacitate the Leeds Health and Care Partnership and its sovereign organisations to ensure that tackling healthcare inequalities is embedded within every aspect of decision-making, resource allocation, and service delivery. It is ultimately about making equity core-business within healthcare. This group has only recently been established but has agreed to initially focus on developing a Health Equity Index. This index will provide the Trust with a simple method to assess its key quality and performance indicators by a measure of equity, enabling us to identify issues, make improvements and track progress.

The Tackling Health Inequalities Toolkit developed through this group has been actively used as part of our service delivery and development programme. The principles of this are now embedded in our Care Services Strategic Plan. The health inequalities priorities derived through the Mental Health Strategy are overseen and driven through the ICB Mental Health Care Delivery Board of which we are key members (with our Medical Director as Chair).

The Trust is a system partner in the Leeds Migrant Health Board (LMHB). The purpose of this work is to significantly improve health outcomes for Leeds migrant communities by providing a strategic, citywide approach to understanding and addressing migrant health needs in Leeds. We are working to strengthen Leeds long-held commitment to support asylum seekers and refugees and help to realise the key ambition to have a strong economy and be a compassionate city. Leeds is a city that celebrates diversity and is a declared City of Sanctuary – recognising the positive contribution of refugees, asylum seekers and others seeking safety to our city.

The Trust is an active contributor to the Synergi Leeds Partnership. This is a partnership between the NHS, Public Health, and the local community and voluntary sectors to tackle the long-standing overrepresentation of people from black, Asian and minority ethnic communities admitted to crisis mental health services or detained under the Mental Health Act.

The Trust has been a key partner in systemwide transformation initiatives, including community mental health. Embedded at the heart of this initiative is co-design of services with underserved and racialised communities.

The Trust is a partner in Creative Spaces: this facilitates solution-focused dialogue, collaborations, and co-designed approaches, to enable health systems interventions to prevent or reduce ethnic inequalities and multiple disadvantages experienced by people with severe mental illnesses. The next event will focus on using commissioning to promote racial equity.

1.2.5.12 – Remembering What’s Forgotten

Remembering What’s Forgotten is a new 12-month hybrid programme and exhibition championing community and lived experience narratives to tackle the overrepresentation of black and South Asian men detained under the Mental Health Act in Leeds.

Co-founded by Synergi-Leeds and Words of Colour, the programme will draw on 50 years of unsung community initiatives, allyship and knowledge to reimagine a more inclusive and equitable mental health system, guided by racial justice.

Using creative and heritage methods, from film, audio, and poetry to archive, co-production and photovoice techniques, the digital and in-person exhibition features the narratives of 60 contributors supported by a curated timeline, categorised under The Past, The Present, The Future.

The programme partners include LYPFT, Leeds City Council and Public Health and Forum Central. Touchstone, Heritage Corner and Leeds Young Authors are co-producing partners while former Leeds United footballer and BBC broadcaster Sanchez Payne is the first project ally to sign up to the programme.

Remembering What’s Forgotten was launched as a hybrid exhibition, online and in person, in Leeds from October 2024, and in dedication to the late Heather Nelson (1965 – 2023), CEO and Founder of the Black Health Initiative who was passionate about equality and justice.

1.2.5.2 – NHS England’s statement on information on health inequalities

In this section of the annual report, the trust exercises its duty to collect, analyse and publish information related to health inequalities as detailed within the NHS England Statement on Information on Health Inequalities. The indicators presented below are the sub-set of indicators applicable to LYPFT within the statement. There are a range of other health inequalities indicators published by acute and community NHS Trusts or at Integrated Care Board level.

1.2.5.2.1 – The rates of Mental Health Act Detentions by Ethnicity

Examining the number of detentions by ethnicity we can see that out of 1301 patients who were detained, 747 (57%) were recorded as White British compared to 73% of the overall population of Leeds. 429 (33%) of patients detained were recorded as being from an ethnically diverse background, compared to 27% of the overall population of Leeds.

Table 1.2F – Number of detentions by ethnicity for the period March 2024 – February 2025
Ethnicity Number of detentions
White – British 747
Not Known 125
Black or Black British – African 87
Asian or Asian British – Pakistani 74
White – Any other White background 46
Mixed – White and Black Caribbean 34
Asian or Asian British – Any other Asian background 33
Black or Black British – Caribbean 31
Other Ethnic Groups – Any other ethnic group 28
Not stated 24
Black or Black British – Any other Black background 14
Asian or Asian British – Indian 14
White – Irish 10
Asian or Asian British – Bangladeshi 10
Mixed – White and Black African 9
Mixed – Any other mixed background 9
Other Ethnic Groups – Chinese 4
Mixed – White and Asian 2

If we compare rates of detention by ethnicity (lower ethnicity breakdown) for the last full year of available data (2023/24), we can see that crude rates of detention per 1000 population differ between ethnic groups. For example, the ethnic group “Mixed – White or Black Caribbean” has a detention rate of 4.4 per 1000 population, which is 4 times higher than “White British” detention rates at 1 per 1000 population. If we analyse the same data by ‘higher ethnicity group’, we can see that Black or Black British groups have a detention rate almost twice as high as White Groups (1.9 per 1000 population compared to 1.0 per 1000 population).

Table 1.2G – Mental Health Act Detention Rate per 1,000 population by ethnicity 2023/24

A horizontal bar chart compares the representation of various ethnic groups using values on a scale from 0 to 5. The ethnic groups are listed along the vertical axis, and the horizontal axis shows values. The group "Mixed – White and Black Caribbean" has the highest value at 4.4, while "Other Ethnic Groups – Chinese" has the lowest at 0.3. Other notable values include "Not Known/Not Stated" at 2.7, "Black or Black British – Caribbean" at 2.6, and "White – Irish" at 1.9. The chart includes a wide range of ethnic categories, including White, Black or Black British, Asian or Asian British, Mixed, and Other Ethnic Groups.
Caption: Bar chart showing representation across ethnic groups, with ‘Mixed – White and Black Caribbean’ having the highest value (4.4) and ‘Other Ethnic Groups – Chinese’ the lowest (0.3). Data spans 17 ethnic categories.

1.2.5.2.2 – The rates of Mental Health Act Detentions by Index of Multiple Deprivation

When reviewing mental health act detentions by Index of Multiple Deprivation (IMD), we can see that broadly most detentions occur in those living in the most deprived areas (IMD1), and the least detentions in the least deprived areas (IMD 10).

Table 1.2H – Mental Health Act Detentions by Index of Multiple Deprivation March 2024 – February 2025

Bar chart showing Mental Health Act Detentions by Index of Multiple Deprivation (IMD) from March 2024 to February 2025. The chart includes ten IMD deciles (1 = most deprived, 10 = least deprived) and an additional '?' category. The highest number of detentions is in the '?' category (401), followed by IMD 1 (294) and IMD 2 (109). The lowest is in IMD 10 (25), showing a trend of higher detentions in more deprived areas.
Caption: Mental Health Act Detentions by Index of Multiple Deprivation, March 2024 – February 2025. The chart highlights a clear trend: individuals from more deprived areas are more likely to be detained under the Mental Health Act, with a notable number of cases where deprivation status is unknown.
This pattern persists even when we take account of the composition of our population. When we examine the rate of mental health act detentions per 1,000 population, we see the highest rates of detention in the most deprived communities and rates of detention progressively lower in more affluent areas (0.9 per 1000 population in IMD 1 compared with 0.4 per 1000 in IMD 10).

Table 1.2I – Mental Health Act Detention Rate per 1,000 population by IMD in 2023/24

Horizontal bar chart showing Mental Health Act detention rates per 1,000 population by Index of Multiple Deprivation (IMD) deciles for 2023/24. IMD deciles range from 1 (most deprived) to 10 (least deprived). The highest detention rate is in IMD 1 at 0.9, followed by IMD 2 at 0.8. The lowest rate is in IMD 8 at 0.3. The chart shows a general trend of higher detention rates in more deprived areas.
Caption: Mental Health Act Detention Rate per 1,000 Population by Deprivation Level, 2023/24. The chart reveals a clear pattern: individuals in more deprived areas (IMD 1 and 2) experience higher detention rates under the Mental Health Act compared to those in less deprived areas.
Similarly, if we examine detained bed days rate by IMD, we can see a clear pattern showing those from the most deprived communities (IMD 1) are detained under the Mental Health Act for a greater proportion of their admission (81%) compared to those living in the least deprived communities (58%). This is mainly a linear pattern, with proportion of detained bed days decreasing with increasing affluence, apart from IMD 5 which has the highest detained bed days rate of 89%.

Table 1.2J – Mental Health Act Detained Bed Days Rate (%) by Index of Multiple Deprivation

Horizontal bar chart showing Mental Health Act Detained Bed Days Rate (%) by Index of Multiple Deprivation (IMD). IMD categories range from 1 (most deprived) to 10 (least deprived), with an additional '?' category. The highest detained bed days rate is in the '?' category, while the lowest is in IMD 10. The chart illustrates a trend of higher detained bed days rates in more deprived areas.
Caption: Mental Health Act Detained Bed Days Rate by Deprivation Level. This chart shows that individuals from more deprived areas tend to have higher rates of detained bed days under the Mental Health Act, with a notable proportion of cases where deprivation status is unknown.

1.2.5.2.3 – The rates of restrictive interventions by Ethnicity

2636 out of 3985 (66%) incidents involving resistive practises occurred to patients recorded as ‘White British’. 1066/3985 (27%) of incidents involving restrictive practises occurred to patients recorded as ethnically diverse.

Table 1.2K – Incidents involving restrictive practises by higher ethnicity breakdown March 2024 – February 2025
Ethnicity Incidents involving restrictive practises
White – British 2636
Not Known 283
White – Any other White background 270
Asian or Asian British – Pakistani 261
Black or Black British – African 142
Mixed – Any other mixed background 127
Asian or Asian British – Any other Asian background 77
Mixed – White and Black African 37
Black or Black British – Any other Black background 32
Other Ethnic Groups – Any other ethnic group 29
Not stated 21
Other Ethnic Groups – Chinese 15
Asian or Asian British – Indian 14
White – Irish 12
Mixed – White and Black Caribbean 12
Black or Black British – Caribbean 11
Asian or Asian British – Bangladeshi 6
Mixed – White and Asian 0
Total 3985

Examining the rate of incidents per 1000 bed days by ethnicity, we can see a variety in rates across ethnic groups. The White British rate is 32.8 per 1000 bed days. Several ethnic groups have a lower incident rate than this, including Black or Black British Caribbean, Black or Black British African or any other black background. Several ethnic groups have a higher rate than White British patients including Mixed – White and Black African and Mixed – any other mixed background.

Table 1.2L – Incidents Involving Restrictive Practises per 1000 Bed Days by Ethnicity March 2024 – February 2025

Bar chart showing the number of incidents involving restrictive practices per 1,000 bed days by ethnicity from March 2024 to February 2025. The x-axis ranges from 0 to 100. Ethnic groups with visible data include: 'Mixed – Any other mixed background' (85.2), 'White – Any other White background' (64.9), 'Asian or Asian British – Pakistani' (37.7), 'Black or Black British – African' (22.1), 'Black or Black British – Any other Black background' (20.6), 'Asian or Asian British – Any other Asian background' (20.4), 'Asian or Asian British – Indian' (8.2), 'Asian or Asian British – Bangladeshi' (4.7), and 'Black or Black British – Caribbean' (4.4).
Caption: Incidents Involving Restrictive Practices per 1,000 Bed Days by Ethnicity (March 2024 – February 2025). The chart highlights significant variation in the use of restrictive practices across ethnic groups, with the highest rates observed among individuals from ‘Mixed – Any other mixed background’ and ‘White – Any other White background’.

1.2.5.2.4 – The rates of restrictive interventions by deprivation

Reviewing incidents involving restrictive practises between March 2024 and February 2025 by deprivation, we can see the highest number of incidents were recorded for patients living in IMD 1 (most deprived communities). Patients living in IMD 5 had the second highest number of incidents involving a restrictive practise.

Table 1.2M – Incidents Involving Restrictive Practices by Index of Multiple Deprivation (IMD), March 2024 – February 2025

Bar chart showing the number of incidents involving restrictive practices by Index of Multiple Deprivation (IMD) from March 2024 to February 2025. The x-axis lists IMD categories from 'Unknown' to 10 (1 = most deprived, 10 = least deprived). The y-axis shows the number of incidents, ranging from 0 to 1,400. The highest number of incidents is in IMD 1 (1,217), followed by IMD 5 (871) and IMD 2 (488). The lowest is in IMD 6 (91). The 'Unknown' category accounts for 185 incidents.
Caption: Incidents Involving Restrictive Practices by Deprivation Level, March 2024 – February 2025. The chart shows that individuals from more deprived areas, particularly IMD 1, experienced significantly more restrictive practice incidents than those from less deprived areas.
The absolute number of incidents involving restrictive practises is high in IMD 1, but when viewed as a rate of per 1000 bed days (Figure 7), it is relatively low compared to other IMD’s (29.6 per 1000 bed days). The highest rate of restrictive practises per 1000 bed days is seen in IMD 9 (63.8 per 1000 bed days).

Table 1.2N – Incidents involving restrictive practises per 1000 bed days by IMD, March 2024 – February 2025

Bar chart showing incidents involving restrictive practices per 1,000 bed days by Index of Multiple Deprivation (IMD) from March 2024 to February 2025. The x-axis lists IMD categories from 'Unknown' to 10 (1 = most deprived, 10 = least deprived). The y-axis ranges from 0 to 140. The highest rate is in the 'Unknown' category (123.5), followed by IMD 9 (63.0), IMD 5 (52.4), and IMD 10 (44.0). The lowest rate is in IMD 6 (10.6).
Caption: Incidents Involving Restrictive Practices per 1,000 Bed Days by Deprivation Level, March 2024 – February 2025. The chart shows variation in restrictive practice rates across deprivation levels, with some of the highest rates recorded in IMD 9 and 5, and a notably high rate in the ‘Unknown’ category.

1.2.5.2.5 Smoking Cessation provided on Inpatient and Maternity Wards

Smoking cessation services are provided on 100% of inpatient wards at the Trust.

1.2.6 – Customer satisfaction scores

1.2.6.1 – Trustwide Feedback measure – Have Your Say

The co-produced and accessible Have Your Say (HYS) feedback measure continues to be an effective way to collect service user and carer feedback about the care they have been provided with, at any time in a person’s care journey.

Feedback for services received via the HYS measure has been overwhelmingly positive over the reporting period, with some service users expressing powerful statements such as “I wouldn’t be here without your care and support” and “You’ve saved my life”. Clinical Team Managers, Clinical Leads and Heads of Services receive a monthly email containing HYS feedback results. A recent introduction has been to include a link to a page which highlights individual staff members by name, who have been identified in positive feedback received from service users and carers.

The table below shows how people have rated their overall experience of the care provided by LYPFT teams and services, over the past 12 months.

Table 1.2O – Feedback from Have Your Say in 2024/25
Month and year Numbers of people who provided feedback Positive rating of overall experience of care OK/Don’t know rating of overall experience of care Negative rating of overall experience of care
April 2024 188 4% 88% 8% 4%
May 2024 194 87% 8% 5%
June 2024 156 90% 3% 6%
July 2024 215 88% 5% 7%
August 2024 159 94% 4% 2%
September 2024 160 90% 7% 3%
October 2024 230 91% 7% 2%
November 2024 185 88% 9% 3%
December 2024 133 92% 2% 6%
January 2025 201 90% 7% 3%
February 2025 162 87% 7% 6%
March 2025 136 91% 6% 3%

The Patient and Carer Experience Team (PCET) hold strategic oversight of a comprehensive HYS dashboard which informs which of our Trust services are using the feedback measure to gather service user and carer feedback, whilst also identifying services that require support. Going forward, the PCET plans to work with the Trust’s Informatics Team to enable services to have immediate access to their own HYS data, ensuring accountability for reporting and acting on feedback received. Over the past year the Gender Identity Service and Chronic Fatigue Service are commended for receiving the largest numbers of feedback, month on month.

HYS drop-in sessions are held every other Friday in the Becklin Centre café area between 10.30am and 12.00pm. These sessions have helped to increase the numbers of feedback received for the Working Age Adult inpatient wards. The drop-in sessions are supported by a PCET member and volunteers from the Trust’s Volunteer Service. Involving volunteers to help collect feedback from service users has been vital, as volunteers can spend quality time with service users, explaining that they are not staff members and therefore giving service users the confidence to give their feedback freely, without worrying that their care may be affected. The volunteers report that supporting the HYS drop-in sessions gives them a sense of purpose and they hear from people who may not usually be heard. Our volunteers, many of whom have experienced mental ill health in the past or are still in receipt of services, provide hope and inspiration to current inpatient service users that recovery is possible and that they can go on to lead purposeful and meaningful lives.

Plans to work closely with the IT team to enable services to send out a link to the HYS questions by text to service users have been temporarily hampered. This is due to regulations around texts not being able to be sent to ask for feedback, unless they have given their explicit consent to do so. The PCET Lead is now part of the Trust’s Patient Portal App Working Group where there are plans to include the link to the HYS questions on the new app. This will hopefully increase the chance of our services, particular our community services, to receive increased numbers of feedback from service users.

1.2.6.2 – Community Mental Health Services 2024 Survey results

The National Service User Survey (NPS) programme was introduced in 2001 by the Department of Health, and subsequently moved to the Healthcare Commission, and then to the Care Quality Commission in April 2009. The results of the most recent Community Mental Health Services 2024 survey were published on 4 April 2024.

The results of the survey showed that Leeds and York Partnership NHS Foundation Trust are predominantly better than the sector scores.

Our highest scores were achieved for the following questions:

  • Thinking about the last time you received therapy; did you have enough privacy to talk comfortably?
  • Did your NHS mental health team treat you with care and compassion?
  • Would you know who to contact out of office hours within the NHS if you had a crisis?
  • Have any of the following been discussed with you about your medication? Purpose of medication
  • Overall, in the last 12 months, did you feel that you were treated with respect and dignity by NHS mental health services?

Our lowest scoring results were in the following questions:

  • In the last 12 months, did your NHS mental health team give you any help or advice with finding support for… Finding or keeping work
  • In the last 12 months, did your NHS mental health team give you any help or advice with finding support for… Cost of living
  • Aside from this questionnaire, in the last 12 months, have you been asked by NHS mental health services to give your views on the quality of your care?
  • In the last 12 months, did your NHS mental health team give you any help or advice with finding support for… Financial advice or benefits
  • Has your NHS mental health team asked if you need support to access your care and treatment?

In response to these results, the Patient and Carer Experience Lead will coordinate and introduce a plan to highlight and celebrate areas where services scored well and to introduce recommendations to improve on the lowest scores.

1.2.7 – Emergency preparedness resilience and response report for 2023/24 statement of readiness and readiness activities

1.2.7.1 – Introduction

The Trust, as an NHS funded organisation, is required to comply with NHS England’s Core Standards for emergency preparedness resilience and response (EPRR). One of these standards requires the organisation to publicly state its readiness and preparedness activities in annual reports within the organisation’s own regulatory reporting requirements. This section meets this requirement.

1.2.7.2 – Reporting for 2024/25

1.2.7.2.1 – 2024 NHS England EPRR Core Standards

The Trust achieved 74% compliance with core standards in 2024. This is classed as non-compliant but represents a significant improvement over the 26% declared in 2023. Overall, the Trust’s position was:

Table 1.2P – Compliance with NHS England EPRR Core Standards 2024
Category Compliant Partially Compliant Non-compliant
NHS England assessment 43 15 0
1.2.7.2.2 – Statement of readiness

2024/25 started positively with a full complement of staff at 3 whole time equivalent (WTE). In November 2024 the EPRR Officer started maternity leave and while some administrative resource was found, this did not mitigate the additional duties around the EPRR Plan areas that the EPRR Officer was responsible for. Subsequently, in March 2025 the Chief Operating Officer’s Executive Assistant was seconded into the EPRR Team to cover the remainder of the maternity leave. On 31 March 2025 the Resilience Lead and Corporate Business Manager retired from the Trust and their post was taken, following a successful interview, by the EPRR Manager. To date the EPRR Manager post remains vacant. While this post remains unfilled, an impact on achievement of compliance with core standards is expected.

1.2.7.2.3 – Overview of readiness activities in 2024/25
  • The Trust’s maintenance of business continuity plans have shown improvement with many services updating their plans onto the most recent template in light of NHS England expecting annual revisions of all plans.
  • In 2024/25 Audit Yorkshire conducted an audit on the Business Continuity Management System. An opinion of Significant Assurance was provided.
  • Work has progressed to improve compliance against EPRR Core Standards for Chemical, Biological, Radiological, and Nuclear (CBRN) and Hazardous Materials (HAZMAT). A full risk assessment and training needs analysis was completed in 2024.
  • All EPRR plans identified in core standards are reviewed annually, and, where deemed non-compliant, are updated with NHS England recommendations. Additional plans are developed to meet any identified gaps.
  • Formal portfolios for Health Commanders at tactical and strategic level are now mandated for NHS organisations. The EPRR team is overseeing compliance of approx. 60 staff.
  • Plans tested in 2024/25 saw all care services teams undertake a desktop exercise which tested elements of all business continuity plans within care services. Lessons identified in the exercises were recorded and are to be embedded into existing plans.

Confirmation from the Chief Executive

As Chief Executive I confirm that the information in this Performance Report is accurate to the best of my knowledge and that I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum.
Signed:
Date: 19 June 2025
Dr Sara Munro
Chief Executive
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2.1 – The Accountability Report (Director’s Report)

The directors are responsible for keeping proper accounting records, which disclose with reasonable accuracy at any time the financial position of the Trust and enable them to ensure that the accounts comply with the requirements outlined in the direction of the Secretary of State. They are also responsible for safeguarding the assets of the Trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

The directors consider that to the best of their knowledge and belief they consider the Annual Report and Accounts, taken as a whole, are fair, balanced and understandable and provide the information necessary for service users, regulators and other stakeholders to assess the Trust’s performance, business model and strategy.

2.1.1 – Members of the Board of Directors

At the end of 2024/25 the Board of Directors was made up of six non-executive directors (including the Chair of the Trust) and seven executive directors (including the Chief Executive). The table below lists members of the Board of Directors on 31 March 2025. It shows the name of the Chair of the Trust and Deputy Chair; the Senior Independent Director; the Chief Executive and the Deputy Chief Executive.

Table 2.1A – Members of the Board of Directors on 31 March 2025

Non-executive Team

Merran McRae Chair of the Trust
Zoe Burns-Shore Non-executive Director
Dr Frances Healey Non-executive Director
Cleveland Henry Non-executive Director (Senior Independent Director)
Kaneez Khan MBE Non-executive Director
Katy Wilburn Non-executive Director
Martin Wright Non-executive Director (Deputy Chair of the Trust)

Executive Team

Dr Sara Munro Chief Executive
Joanna Forster Adams Chief Operating Officer
Dawn Hanwell Chief Financial Officer (Deputy Chief Executive)
Darren Skinner Director of People and Organisational Development
Dr Chris Hosker Medical Director
Nichola Sanderson Director of Nursing and Professions

Non-executive directors (NEDs), including the Chair of the Trust, are appointed by the Council of Governors. Where there is a vacancy this would be filled through a full open advertisement process. A non-executive director is appointed for an initial period of up to three years, subject to satisfactory appraisal by the Chair of the Trust. Where there is an incumbent NED who is eligible for re-appointment by virtue of the number of years they have served and where they wish to be considered for re-appointment, this would be done based on a satisfactory appraisal and approval by the Council of Governors. A non-executive director may be re-appointed for a second term of up to three years. Should it be necessary to remove either the Chair of the Trust or any of the other non-executive directors this would be done by the Council of Governors. A decision to remove the Chair of the Trust or another non-executive director must be done in accordance with our constitution and only if three quarters of the total number of governors appointed or elected at the time, vote to remove the individual.

The Board of Directors considers that it is balanced, complete and appropriate and this can be seen in the biographical details of Board members as set out in Part A section 3.3 of this Annual Report. The non-executive directors are considered to be independent in both judgement and character, and the Board has confirmed there are no relationships or circumstances which are likely to affect, or could appear to affect, judgment in this respect. It should be noted that Martin Wright has served on the Trust board for more than six years from the date of his first appointment. This was agreed by the Council of Governors in 2023. In making this decision, the Council recognised the need to have stability on the Board at a time of transition, following a number of changes to the NED team and a newly appointed Chair of the Trust. It acknowledged the need to appoint External Auditors in 2024/25, which the Chair of the Audit Committee would be involved in and also recognised the knowledge Martin had of the Trust’s complex Private Finance Initiative (PFI) arrangements which are in a period of significant transition.

It is also reported that Merran McRae, the Chair of the Trust, had no other significant commitments during the year 2024/25 which affected her ability to carry out her duties to the full, and she has been able to allow sufficient time to undertake these duties.

Further information about the Board of Directors can be found in Part A sections 2.2 and 3 of this Annual Report.

2.1.2 – Register of Directors’ Interests

Under the provisions of the constitution, we are required to have a register of interests to formally record any declarations of interests of members of the Board of Directors. The register includes details of all directorships and other relevant material interests, which both executive and non-executive directors have declared.

On appointment and annually thereafter, members of the Board of Directors must declare any interests, which might place, or be seen to place them in a potential conflict of interest between their personal or private interests and those arising from their membership of the Board of Directors. None of the interests declared conflict with their role as a director.

Members of the Board of Directors are also required to declare any conflict or pecuniary interests that arise in the course of conducting Trust business. An opportunity to do this is provided at every internal meeting they attend.

The register of interests is maintained by the Associate Director for Corporate Governance and is available for inspection on the Trust’s website. The Associate Director for Corporate Governance can be contacted by emailing Clare Edwards.

2.1.3 – Disclosure for the payment of creditors

We adopt the Better Payment Practice Code, which requires payment of all our undisputed invoices by the due date or within 30 days of receipt of goods. Further information can be found in note 9 of the Annual Accounts in Part B of this Annual Report. There has also been no interest paid under the Late Payment of Commercial Debts (Interest) Act 1998.

2.1.4 – Income disclosure

The Trust is required under Section 43(2A) of the NHS Act 2006 (as amended by the Health and Social Care Act 2012) to ensure that income from the provision of goods and services for the purposes of the health service in England is greater than its income from the provision of goods and services for any other purposes. The Trust has met this requirement in 2023/24. The Board of Directors, therefore, declares that there has been no material income other than from the provision of goods and services for the purposes of the health service in England. Any benefit is re-invested in the provision of those services.

2.1.5 – Cost allocation and charging

The Trust has complied with the cost allocation and charging requirements set out in the HM Treasury and the Office of Public Sector Information guidance.

2.1.6 – Political and charitable donations

The Board reports that it has not made any political or charitable donations and that it is not the policy of the Leeds and York Partnership NHS Foundation Trust to make any such payments.

2.1.7 – NHS England’s well-led framework

The Board can report there are no material inconsistencies between the Annual Governance Statement and the information within the Annual Report. It can also be reported that the Trust was rated overall ‘good’ in the last CQC inspection with the well-led domain also being rated as ‘good’.

More information on the arrangements in place to ensure services are ‘well-led’ can be found in the Annual Governance Statement in Section 2.7 of the Annual Report.

The Trust is registered with the CQC and is fully compliant with the registration requirements. Compliance with the CQC fundamental standards of quality and safety are one of the elements of the organisation’s risk management process.

Following a CQC inspection we will take a Trustwide view of the themes and have a holistic approach to resolving any issues and reducing the risk of non-conformity across the Trust. We ensure that the programme of activities and projects are working together and that benefits and improvements are brought to all core services.

Quality and Safety Peer Reviews act as an internal assessment against regulatory compliance and standards. A standardised tool kit has been developed aligned to the CQC’s quality statements which are used to guide and direct their inspections of care services. Through the use of the standardised framework, areas for improvement, risks to service delivery and areas of good practice are identified. Experience from within the organisation is drawn upon to identify a team to effectively carryout the quality and safety review. Any must do or should do actions from the latest CQC inspection or Mental Health Act Inspection form part of the review and evidence is gathered to provide assurance that actions have been addressed and embedded.

Recommendations and actions are monitored through local governance systems to ensure progress and oversight. A system is in place to ensure that any recommendations and opportunities identified for learning, both at a service and organisational level, are shared through the governance structure. Any areas of concern are escalated through the Unified Clinical Governance Group.

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2.2 – The Accountability Report (Remuneration Report)

2.2.1 – Introduction

In company law, senior managers are defined as ‘those persons in senior positions having authority or responsibility for directing or controlling the major activities of the foundation trust’. For the purpose of this Remuneration Report, the description ‘senior managers’ refers to the executive and non-executive directors holding positions on the Board of Directors.

This Remuneration Report contains details of senior managers’ remuneration and pensions. It also sets out further information about the appointment of those senior managers (where these have occurred during 2024/25) as required by NHS England’s Code of Governance for NHS Provider Trusts. The narrative and figures in this report relate to those individuals who have held office as a senior manager during 2024/25.

The information in sections 2.2.2 to 2.2.5 below is not subject to audit by our external auditors, KPMG; however, they will read the narrative to ensure it is consistent with their knowledge of our Trust.

2.2.2 – Annual statement on remuneration

The information provided in Sections 2.2.2 to 2.2.4 forms the annual report from the chair of the committees that are responsible for the remuneration of the executive and non-executive directors. The Chair of these committees is the Chair of the Trust.

Remuneration for senior managers is determined by two sub-committees: the Remuneration Committee (a sub-committee of the Board of Directors made up of all the non-executive directors), which is responsible for the remuneration for the executive directors; and the Appointments and Remuneration Committee (a sub-committee of the Council of Governors made up of a majority of governors), which is responsible for the remuneration for the non-executive directors.

The policy of the two sub-committees is that salaries for executive directors and the remuneration for non-executive directors will be benchmarked periodically or when there is a fundamental change in the level of payment. Where any level is set over and above the Civil Service Threshold of £150,000 per annum, consideration will be made to ensure this is set at a reasonable level. This will include taking account of any guidance received from NHS England in relation to Very Senior Managers (VSM) salaries including any recommendations on pay uplift; the level of complexity in relation to the role and the landscape in which the Trust is operating; any additional responsibility outside the organisation for example leading at a regional or national level; and any effect of market forces that might be pertinent to the role.

2.2.2.1 – Remuneration Committee – executive directors’ remuneration

With regard to executive directors, the overarching policy of the Remuneration Committee is set out in the Trust’s VSM pay policy. In applying the policy the committee will: use benchmarked figures to ensure they are in line with other similar organisations; ensure equity within the executive team pay structure, taking account of levels of experience; and reference to NHS England guidance on Very Senior Managers (VSM) salaries. A further consideration when determining the overall level of remuneration is the differential between the amount paid to an executive director and their direct reports to ensure the overall level of responsibility for executive directors is recognised. When awarding percentage pay uplifts (‘cost of living awards’) the committee is always mindful of the guidance from NHS England which will be used as a benchmark. There is no performance-related pay in any director’s current contract of employment. Where a salary requires review, a benchmarking exercise may be requested to make comparison against other similar NHS organisations and similar posts.

Further information about the work of the Remuneration Committee during 2024/25 can be found in section 2.2.4.2 below.

2.2.2.2 – Appointments and Remuneration Committee – non-executive directors’ remuneration

The overarching policy for the remuneration of the non-executive directors (NEDs) is to award levels in line with other comparable NHS foundation trusts, using benchmarked figures and taking account of any guidance issued by NHS England. When awarding annual percentage uplifts (‘cost of living’ awards) to non-executive directors the committee will be mindful of the amount awarded to executive directors and to staff on Agenda for Change (AfC) pay bandings.

Further information about the work of the Appointments and Remuneration Committee during 2024/25 can be found in section 2.2.4.3 below.

2.2.3 – Senior managers’ remuneration policy

2.2.3.1 – Future policy tables

This section describes the policy narrative relating to the components of the remuneration packages for executive and non-executive directors. Each of the components detailed in these tables supports the Trust’s Strategic Objective 2: we provide a rewarding and supportive place to work (putting in place a benchmarked remuneration package to fairly remunerate our Board members; recognising the liability and responsibility they carry; attracting an appropriately skilled and qualified senior team to lead the organisation).

The future policy tables 2.2A and 2.2B refer to the reporting and performance period 1 April 2024 to 31 March 2025.

Table 2.2A – Remuneration policy for executive directors
Element Policy
Salary The overarching policy of the Remuneration Committee is to: use benchmarked figures to ensure they are in line with other similar organisations; ensure equity within the executive team pay structure, taking account of levels of experience; and reference to the NHS England guidance on VSM salaries. A further consideration when determining the overall level of remuneration is the differential between the amount paid to an executive director and their direct reports.

There are no annual increments associated with executive directors’ salaries.

A time-limited additional payment of up to 10% of salary may be payable for undertaking the Senior Responsible Officer role within the Integrated Care System.
Taxable benefits In the main this will be any mileage rates paid which are over and above the HMRC threshold or any other benefit in kind applicable at the time of remuneration.
Annual performance related bonuses The Trust does not pay any annual performance-related bonuses to executive directors. (Section 2.2.3.2 below sets out the process for performance appraisals (not linked to pay)).
Long-term performance-related benefits The Trust does not pay long-term performance related bonuses to executive directors. (Section 2.2.3.2 below sets out the process for performance appraisals (not linked to pay)).
Pension-related benefits Pension rights for executive directors are determined by the NHS Pension Scheme, and the maximum payable (by the employee and the employer) is determined by the NHS Pension Scheme.
Percentage uplift (cost of living increase) The Remuneration Committee will decide if the executive directors are to be awarded a percentage uplift (‘cost of living’ increase) for each financial year and what level this will be. In doing this the committee is mindful of the national advisory or mandatory rate for VSM issued by NHS England.
Other remuneration (e.g. relocation expenses) Any other expenses paid to executive directors would be paid in accordance with the relevant Trust policy. There are no items of other expenditure which are applicable only to executive directors. Relocation expenses are available to new executive directors under the Trust’s Relocation Procedure

It should be noted that the executive directors’ contract allows the Trust to recover any monies owed at any time via deductions from salary.

Table 2.2B – Remuneration policy for non-executive directors
Element Policy
Fee payable The overarching policy for the remuneration of the non-executive directors (NEDs) is to award levels in line with other comparable NHS foundation trusts using benchmarked figures. The Council of Governors will also keep under review any guidance issued by NHS England and take this into consideration when setting levels of remuneration.

The maximum amount that can be paid will be determined by the Appointments and Remuneration Committee and ratified by the Council of Governors. There are no annual increments associated with non-executive directors’ remuneration.
Additional fees for any other duties The remuneration for the Chair of the Trust recognises the specialist role and extra time commitment over and above that of the other NEDs. The Chair of the Audit Committee is also remunerated differently in recognition of the specific skills and responsibility this role requires. The Senior Independent Director is also remunerated differently in recognition of the responsibility this role requires. All other NEDs are remunerated equally; however, for those NEDs who chair a Board sub-committee (excluding the Audit Committee, which attracts a separate level of remuneration) there is an honorarium of £1,000 per annum (paid pro-rata). This honorarium is in recognition of the added workload and responsibility that comes with chairing a Board sub-committee.

The maximum amount that can be paid will be determined by the Appointments and Remuneration Committee and ratified by the Council of Governors.
Percentage uplift (cost of living increase) The Appointments and Remuneration Committee will decide if the NEDs will be awarded a percentage uplift (‘cost of living’ increase) and what level this will be. In doing this the committee is mindful of the uplift awarded to staff on AfC pay bandings and any percentage uplifts awarded to the executive directors..
Travel Travel costs will be reimbursed through the payroll and will be submitted on a completed travel claim form supported by receipts. Costs incurred will be reimbursed on a like-for-like basis with mileage being paid at a fixed pence per mile.
Pension contributions No pension deductions are made from non-executive directors’ remuneration and no contribution is made to a pension fund in respect of any non-executive director.
Other remuneration (e.g. relocation expenses) Any other expenses paid to non-executive directors would be paid in accordance with the relevant Trust policy. There are no items of other expenditure which are applicable only to non-executive directors.

There have been no new components of the remuneration package for either the executive directors or non-executive directors since the last remuneration report.

It should be noted that employees of the Trust are paid on AfC bandings with an incremental scale; executive and non-executive directors are paid on a fixed salary which has no element of incremental scale. The level of salary paid to those on AfC is determined nationally, whereas the remuneration of the executive and non-executive directors are determined by the Remuneration Committee and the Appointments and Remuneration Committee respectively, informed by appropriate policy and benchmarking data.

The Trust has not consulted with staff when setting directors’ or VSM remuneration policy with the exception of the policy for non-executive directors where staff governors have been involved in determining their remuneration.

2.2.3.2 – Performance and appraisals

2.2.3.2.1 – Overview

Performance and appraisals are not linked to remuneration and there is no element of performance related pay in senior managers’ salaries or remuneration packages.

The Board of Directors and its committees are committed to continuous improvement and it undertakes an evaluation of their performance. We also have in place an evaluation process for members of the Board with information from this being fed into the appraisals of individual members.

The appraisal of individual Board members identifies strengths and good performance, and also areas for development. The appraisal looks at an individual’s development needs, which informs tailored development plans and objectives.

All executive and non-executive directors undertake compulsory training. Furthermore, regular Board of Directors’ strategic development sessions take place with some being used specifically for Board development. In addition to any internal development or training sessions non-executive directors and executive directors will also attend external training and development courses as required. A dedicated Board Development Programme was commissioned in 2024/25 to support further development and training based on the findings of a gap analysis undertaken in 2023/24.

The processes described in sections 2.2.3.2.2 and 2.2.3.2.3 below refer to the performance and appraisals of the executive and non-executive directors for the period 1 April 2024 to 31 March 2025.

2.2.3.2.2 – Executive Directors

Objectives are set for each executive director in conjunction with the Chief Executive (the Chief Executive’s objectives are set in discussion with the Chair of the Trust). These objectives are monitored through the appraisal process. The Chair of the Trust carries out the appraisal of the Chief Executive against agreed objectives, and appraisals for the other executive directors are carried out by the Chief Executive against their agreed objectives. As required, the Chair of the Trust and the non-executive directors will contribute to the appraisal of each executive director in regard to their performance as a member of the unitary Board. This will be fed back to the Chief Executive for inclusion in their overall appraisal.

The Remuneration Committee has been assured that a process for appraisal is in place and has been completed for each executive director including the Chief Executive. Any areas of concern about the performance of any of the executive directors will be reported to the committee with an assurance on the proposed remedial action.

2.2.3.2.3 – Non-executive Directors

Objectives are set for each of the non-executive directors in conjunction with the Chair of the Trust (the Chair’s objectives are set in discussion with the Senior Independent Director and Lead Governor). Performance against these is monitored through one-to-one meetings and annual appraisals.

The NEDs have their objectives agreed with the Chair in conjunction with the Lead Governor. Annual appraisals of the non-executive directors are carried out by the Chair of the Trust with the Lead Governor in attendance. The Senior Independent Director conducts the annual appraisal of the Chair of the Trust again in conjunction with the Lead Governor. Where required, governors and members of the Board are invited to provide feedback on each of the NEDs and the Chair which informs the appraisal discussion. The Council of Governors has received assurance that a process is in place and has been completed effectively.

Any areas of concern about the performance of any non-executive director will be reported to the Appointments and Remuneration Committee along with an assurance on the proposed remedial action and a summary report would be made to the Council of Governors.

2.2.3.3 – Policy on payment for loss of office and notice periods

All contracts for executive directors are permanent and therefore open-ended. The period of notice for each executive director is set out in their contract and is normally three months. Non-executive directors do not have a contract of employment; they have a letter of appointment. Non-executive directors are not subject to employment law or regulations and as such do not have a formal period of notice.

The executive directors’ contract contains details of the grounds on which a director’s contract may be terminated. The contract also contains information about the circumstances under which PILON (payment in lieu of notice) may be paid.

Payment for loss of office or in lieu of notice does not apply to non-executive directors as they are appointed not employed.

2.2.3.4 – Policy on diversity and inclusion

The Trust believes in fairness and equality and above all values diversity and inclusion in all aspects of work, this includes within our Board. The Nominations Committee, which appoints the executive directors and the Appointments and Remuneration Committee, which appoints our non-executive directors will, with each new appointment to the Board of Directors, consider matters of diversity and equity. The committees will act within the requirements of the Trust’s diversity and inclusion policies in order to meet the Trust’s overall aim of providing outstanding mental health and learning disability services as an employer of choice. Whilst maintaining the diversity of the Board is one of our main considerations in any appointment, ensuring that the right person is in post is important so the Board continues to be fit for purpose.

The Trust’s policies and processes take full account of the requirements of the Equality Act 2010 and the associated public sector equality duties. This includes specific requirements to make reasonable adjustments to systems or processes for a person with a disability. Details are set out in our Equality, Diversity and Human Rights policy.

We have in place systems for monitoring equality progress and compliance against our People Plan 2024 – 2027 through our workforce governance structure including the Workforce Committee, which also includes reporting to the Board on performance against our target measures and the publication of our gender pay gap, Workforce Race and Workforce Disability Standard data and annual actions. Details on our progress can be found on our Equality and Diversity page.
Indicator nine of the NHS Workforce, Race, Equality, Standard is for Board representation only. Total Board member representation by ethnicity is 15.4% (11 Board members are white and two Board members are from ethnic minorities) and overall workforce is 23.1%, therefore a difference in representation is 7.7%.

Table 2.2C – Ethnic diversity of the Directors against senior managers/direct reports and employees
Group Ethnic minorities White Not Stated
Directors 15.4% 84.6% 0%
Senior managers/direct reports (Band 8 and above) 9.87% 85.97% 4.16%
Employees 23.1% 74% 2.9%

More information on the Trust’s policy on diversity and inclusion can be found in Section 2.3.20.

2.2.4 – Annual report on remuneration

This section includes a description of the work of the committees that are involved in the appointment of both the executive and non-executive directors, and which determines their respective salaries and remuneration.  These are:

  • The Remuneration Committee (a committee of the Board of Directors) which is made up of all the non-executive directors and is chaired by the Chair of the Trust
  • The Appointments and Remuneration Committee (a committee of the Council of Governors) which is made up of a majority of governors and is chaired by the Chair of the Trust (unless the Chair is conflicted in any agenda item in which case the committee would be chaired by the Deputy Chair of the Trust or Lead Governor as appropriate)
  • The Nominations Committee (a committee of the Board of Directors) which is made up of a mix of executive and non-executive directors (NEDs) and is chaired by the Chair of the Trust.

2.2.4.1 – Executive directors’ period of employment as Board members

Details of the start date for the Chief Executive and other members of the Executive Team who have served on the Board during 2024/25 are set out in the table below.

Table 2.2D – Executive directors who have served during 2024/25
Name Title Date appointment effective from Date left the Board position
Dr Sara Munro Chief Executive 5 September 2016 N/A
Joanna Forster Adams Chief Operating Officer 3 July 2017 N/A
Dawn Hanwell Chief Financial Officer (Deputy Chief Executive) 1 August 2012 N/A
Dr Chris Hosker Medical Director 1 August 2020 N/A
Darren Skinner Director of People and OD 1 August 2022 N/A
Nichola Sanderson Director of Nursing and Professions 1 June 2023 N/A

Details of the non-executive directors who have served during 2024/25 are shown in the table below along with details of their terms of appointment.

Table 2.2E – Non-executive directors that have served during 2024/25
Name Date appointment effective from Term on which appointed Date appointment is expected to end or has ended Number of the term of office
Merran McRae (Chair of the Trust) 1 January 2023 3 years 31 December 2025 First
Zoe Burns-Shore 15 November 2023 3 years 14 November 2026 First
Dr Frances Healey 1 September 2022 3 years 31 August 2025 First
Cleveland Henry 1 April 2023 3 years 31 March 2026 Second
Kaneez Khan 1 November 2022 3 years 31 October 2025 First
Martin Wright 19 January 2024 3 years 18 January 2027 Third
Katy Wilburn 26 June 2023 3 years 25 June 2026 First

More information on the changes in the NED team during 2024/25 can be found in Section 2.2.4.3 below.

2.2.4.2 – The Remuneration Committee (a committee of the Board of Directors)

The Remuneration Committee is a committee of the Board of Directors.  It has been established in accordance with the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and operates in accordance with the principles in NHS England’s Code of Governance for Foundation Trusts.  It is chaired by the Chair of the Trust and is made up of all the non-executive directors.  A copy of the Terms of Reference for this committee is available on our website.

The committee has a key role in providing the Board with assurance that: executive directors are rewarded appropriately; appropriate contractual arrangements are in place; that there is a process for assessing the performance of individual executive directors against their agreed objectives, and that plans are in place to address any areas of development.

The Remuneration Committee is independent of the executive arm of the Board of Directors.  However, during 2024/25 the committee took advice from Dr Sara Munro, Chief Executive, who provided information regarding the VSM Pay Award, the salaried General Practitioner (GP) pay structure, and the bank staff pay award.  In taking this advice the committee was mindful of any potential conflicts of interest and has dealt with these appropriately as evidenced in the minutes.

The Remuneration Committee has a key role regarding the recruitment and retention of appropriately qualified and experienced executive directors.  It does this by agreeing appropriate reward packages. It exercises scrutiny of the remuneration of executive directors in regard to both salary and other areas of reward and has a core responsibility to ensure compliance with all legal obligations and regulations in respect of the employment and remuneration of executive directors.

During 2024/25 the committee met on one occasion with membership being made up of the Chair of the Trust and six non-executive directors.  Its main areas of business were:

  • Noting and supporting the imposed pay award for VSM of 5% increase for the executive directors for the period 2024/25 to be paid with effect from 1 April 2024
  • Noting and supporting the local pay framework for salaried GPs
  • Noting and supporting a pay uplift for colleagues on the staff bank

The membership of the Remuneration Committee is all the NEDs plus the Chair of the Trust.  The table below shows the Remuneration Committee meetings that each member attended.

Table 2.2F – The Remuneration Committee
Name 26 September 2024
Merran McRae (chair of the committee) Attendance
Zoe Burns-Shore Attendance
Cleveland Henry Attendance
Frances Healey Attendance
Kaneez Khan Board members who sent apologies during 2024/25
Martin Wright Attendance
Katy Wilburn Attendance

2.2.4.3 – The Appointments and Remuneration Committee (a sub-committee of the Council of Governors)

The term non-executive director used in this section refers to all non-executives, including the Chair of the Trust.

The Appointments and Remuneration Committee is a committee of the Council of Governors. It has been established in accordance with the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and operates in accordance with the principles of NHS England’s Code of Governance for Foundation Trusts. It sets the remuneration and terms of service for the non-executive directors, and it also plays a role in the appointment of non-executive directors, particularly in respect of the interview panels which are normally made up of members of the committee.

The committee meets as required and is made up of governors chosen by ballot by members of the Council to represent them. It is chaired by the Chair of the Trust and is supported by the Director of People and OD and the Associate Director for Corporate Governance. If the Chair of the Trust is conflicted in any agenda item, the committee will be chaired by the Deputy Chair of the Trust or the Lead Governor as appropriate. At the end of 2024/25 its membership was made up of Ian Andrews, Matthew Knight, Nicola Lister, Peter Ongley, and Oliver Beckett, all of whom are elected governors. It should also be noted that Les France and Ivan Nip also served on the committee in 2024/25 but stepped down in December 2024 after serving on the committee for the maximum of six years. Peter Ongley and Nicola Lister became members of the Committee after the meeting took place, therefore were not eligible to attend.

In 2024/25 there was one formal meeting of the Appointments and Remuneration Committee. The table below shows the attendance of members at the meeting.

Table 2.2G – The Appointments and Remuneration Committee
Name 15 October 2024
Merran McRae (chair of the committee) Attendance
Ian Andrews Attendance
Oliver Beckett Governors who sent apologies during 2024/25
Les France (Lead Governor) Governors who sent apologies during 2024/25
Matthew Knight Governors who sent apologies during 2024/25
Nicola Lister Governor was not eligible to attend the meeting
Peter Ongley Governor was not eligible to attend the meeting
Ivan Nip Governors who sent apologies during 2024/25

In 2024/25 the main areas of work for the committee were:

  • Approving the re-appointment of Martin Wright as Deputy Chair of the Trust
  • Receiving and considering a report on the outcome of appraisals of the non-executive directors’ and Chair of the Trust.

It should be noted that any decisions taken by the committee must be ratified by the Council of Governors.

2.2.4.3.1 – The process of appointment and re-appointment for non-executive directors

Where there is a non-executive director vacancy the appointment is normally carried out through a competitive interview process.  However, where there is an incumbent NED and they are eligible by virtue of the number of years they have served in the Trust as a NED, and where they wish to be considered for re-appointment, the Council of Governors can agree to re-appoint the individual for a second term of office of up to three years subject to a satisfactory appraisal.

2.2.4.3.2 – Competitive interview process

The first step in any appointment process is for the Nominations Committee (a committee of the Board of Directors) to define the skills and experience required on the Board and to agree a role profile and person specification.  The Appointments and Remuneration Committee receives the agreed role profile and person specification, against which appointments are made.  It is also the responsibility of the committee to agree the process and timetable for any appointment process.  The process and timetable will then be ratified by the Council of Governors.

Candidates can be sought using external search companies, local networks and through the NHS Jobs website.  A panel consisting of a majority of governors led by the Chair of the Trust will draw up a shortlist of candidates from the applicants.  Where the role being recruited to is for the Chair of the Trust, the shortlisting panel will usually be led by the Senior Independent Director.

An interview panel will be formed from the membership of the Appointments and Remuneration Committee with a majority of governors (where possible four governors), the Chair of the Trust and an independent assessor.  The panel will then conduct the interviews and choose the preferred candidate based on merit.  Once the panel has made its choice, a recommendation is made to the Council of Governors and it is for the Council to ratify the recommended appointment at a general meeting.

2.2.4.3.3 – Re-appointment process

In regard to the re-appointment process, the Chair of the Trust will meet with the non-executive director concerned to discuss their performance and preference in relation to re-appointment. Where the process is for the re-appointment of the Chair of the Trust, the Chair will meet with the Senior Independent Director and the Lead Governor.

The most recent appraisal will be used to inform the meeting and the Lead Governor will have been present as part of that appraisal. A report will be made to the Council of Governors by the Chair who will advise if the appraisal has been satisfactory and if the non-executive director wishes to be considered for re-appointment. The Council of Governors will then be asked to ratify their re-appointment. If the Council has evidence that this it is not appropriate to re-appoint the individual then a competitive interview process will be carried out and the individual’s appointment as a NED will come to an end at a date agreed by the Council of Governors.

2.2.4.3.4 – Appointment / re-appointment of non-executive directors in 2024/25

In 2024/25 there were minimal changes within the non-executive director team. Below are more details of the change.

  • The Council of Governors considered and agreed Mr Wright being reappointed as Deputy Chair of the Trust for the period that covers 19 January 2025 to 19 January 2027.

2.2.4.4 – The Nominations Committee (a committee of the Board of Directors)

The Nominations Committee is a committee of the Board of Directors. It has been established in accordance with the NHS Act 2006 (as amended by the Health and Social Care Act 2012) and NHS England’s Code of Governance for Foundation Trusts.

Its role is to: regularly review the structure, size and composition of the Board of Directors and make recommendations for changes where appropriate; identify the skills, knowledge and experience required for vacant director posts (for both executive and non-executive directors); and ensure there are arrangements in place for succession planning within the Board.

Where the vacant post is for a non-executive director, the Nominations Committee will provide the Council of Governors’ Appointments and Remuneration Committee with details of the agreed skills and experience required. Where the vacant post is for an executive director a panel, constituted in accordance with the NHS Act 2006 (as amended by the Health and Social Care Act 2012), made up of a majority of non-executive directors, will lead on the appointment process to appoint to the skill set by a process agreed by the Nominations Committee

The Nominations Committee meets as required. It is chaired by the Chair of the Trust and its membership is made up of the Chief Executive, the Director of People and OD and two non-executive directors. The choice of which NED will be on the committee at any given meeting will depend on them not having a conflict of interest in any matter under discussion at that meeting. The committee is supported by the Associate Director for Corporate Governance who provides secretariat support and advice on governance matters.

During 2024/25 the committee was not required to meet.

2.2.4.4.1 Appointment of executive directors in 2024/25

In 2024/25 there were no events within the executive director team that need to be reported.

Information in sections 2.2.5 to 2.2.7 is subject to audit by our external auditors, KPMG.

2.2.5 – Directors and governors’ expenses

The following table sets out the total paid to directors (executive and non-executive) and governors for out-of-pocket expenses during 2024/25.

Table 2.2H – Directors and governors’ expenses

2024/2025
Role Number in office throughout the reporting period Number receiving expenses in the reporting period The aggregate sum paid in the reporting period £’00
Executive directors 6 5 39
Non-executive directors 7 3 12
Governors 27 2 1

Appointed governors have not been included in this figure as their organisations pay the cost of travel.

2023/2024
Role The aggregate sum paid in the reporting period£’00
Executive directors 71
Non-executive directors 28
Governors 0

Appointed governors have not been included in this figure as their organisations pay the cost of travel.

Expenses relating to executive and non-executive directors are shown in more detail in the expenses payments column in table 2.2J below.

2.2.6 – Senior employees’ pension entitlements, remuneration and benefits in kind

Accounting policies for pensions and other retirement benefits are set out in the notes to the annual accounts; see Part B of this Annual Report. The disclosure on senior employees’ remuneration and pension entitlements is subject to audit by our external auditors, KPMG.

Information about pension entitlements, remuneration and benefits in kind are set out in table 2.2I and 2.2J below

Table 2.2I – Pension entitlement for senior employees (executive directors)

Name and title Real increase in pension at pension age
(Bands of £2500)
£’000		 Real increase in pension lump sum at pension age
(Bands of £2500)
£’000		 Total accrued pension at 31 March 2025
(Bands of £5000)
£’000		 Lump sum at pension age related to accrued pension at 31 March 2025
(Bands of £5000)
£’000		 Cash equivalent transfer value at 1 April 2024
£’000		 Real increase in cash equivalent transfer value
£’000		 Cash equivalent transfer value at 31 March 2025
£’000		 Employer’s contribution to stakeholder pension
£’000
Dr Sara Munro (Chief Executive) 2.5 – 5 0 – 2.5 65 – 70 165 – 170 1,231 25 1,364 0
Joanna Forster Adams (Chief Operating Officer) 0 – 2.5 0 – 2.5 65 – 70 175 – 180 1,484 28 1,631 0
Dawn Hanwell (Chief Financial Officer and Deputy CEO) 0 – 2.5 0 – 2.5 0 – 5 0 – 5 0 0 0 0
Dr Chris Hosker (Medical Director) 2.5 – 5 7 – 7.5 45 – 50 115 – 120 828 76 979 0
Darren Skinner (Director of People and OD) 2.5 – 5 0 – 2.5 15 – 20 15 – 20 283 30 349 0
Nichola Sanderson (Director of Nursing and Professions) 0 – 2.5 0 – 2.5 30 – 35 85 – 90 669 0 712 0

Non-executive directors do not receive pensionable remuneration and consequently there are no entries for them in this report.

The Chief Financial Officer has not contributed to pension schemes this financial year.

Table 2.2J – Remuneration and benefits in kind for senior staff

2024/25
Name and title Salary and Fees
(bands of £5000)		 Taxable benefits
(to nearest £100)		 Annual performance-related bonuses
(bands of £5000)		 Long-term performance-related bonuses
(bands of £5000)		 All pension related benefits
(bands of £2,500)		 Other remuneration
(bands of £5,000)		 Total
(bands of £5000)
Dr Sara Munro (Chief Executive) 210 – 215 1300 0 – 5 0 – 5 27.5 – 30 0 – 5 240 – 245
Dawn Hanwell (Chief Financial Officer and Deputy CEO) 170 – 175 1200 0 – 5 0 – 5 0 – 2.5 0 – 5 175 – 180
Joanna Forster Adams (Chief Operating Officer) 145 – 150 0 0 – 5 0 – 5 15 – 17.5 0 – 5 165 – 170
Nichola Sanderson (Director of Nursing and Professions) 120 – 125 1300 0 – 5 0 – 5 0 – 2.5 0 – 5 120 – 125
Dr Chris Hosker (Medical Director) 210 – 215 900 0 – 5 0 – 5 82.5 – 85 0 – 5 295 – 300
Darren Skinner (Director of People and OD) 135 – 140 0 0 – 5 0 – 5 35 – 37.5 0 – 5 175 – 180
Cathy Woffendin (Director of Nursing, Professions, and Quality) 0 – 5 0 0 – 5 0 – 5 0 – 2.5 0 – 5 0 – 5
Merran McRae (Chair of the Trust) 50 – 55 0 0 – 5 0 – 5 0 – 2.5 0 – 5 50 – 55
Martin Wright (Non-executive Director) 15 – 20 100 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Cleveland Henry (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Kaneez Khan (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Frances Healey (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Zoe Burns-Shore (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Katy Wilburn (Non-executive Director) 10 – 15 0 0 – 5 0 – 5 0 – 2.5 0 – 5 10 – 15
Helen Grantham (Non-executive Director) 0 – 5 0 0 – 5 0 – 5 0 – 2.5 0 – 5 0 – 5
2023/24
Name and title Salary and fees
(bands of £5000)		 Taxable benefits
(to nearest £100)		 Annual performance-related bonuses
(bands of £5000)		 Long-term performance-related bonuses
(bands of £5000)		 All pension related benefits
(bands of £2,500)		 Other remuneration
(bands of £5,000)		 Total
(bands of £5000)
Dr Sara Munro (Chief Executive) 200 – 205 0 0 – 5 0 – 5 0 – 2.5 0 – 5 200 – 205
Dawn Hanwell (Chief Financial Officer and Deputy CEO) 165 – 170 0 0 – 5 0 – 5 0 – 2.5 0 – 5 165 – 170
Joanna Forster Adams (Chief Operating Officer) 140 – 145 0 0 – 5 0 – 5 0 – 2.5 0 – 5 140 – 145
Nichola Sanderson (Director of Nursing and Professions) 95 – 100 300 0 – 5 0 – 5 720 – 722.5 0 – 5 820 – 825
Dr Chris Hosker (Medical Director) 190 – 195 300 0 – 5 0 – 5 0 – 2.5 0 – 5 190 – 195
Darren Skinner (Director of People and OD) 135 – 140 0 0 – 5 0 – 5 30 – 32.5 0 – 5 165 – 170
Cathy Woffendin (Director of Nursing, Professions, and Quality) 20 – 25 0 0 – 5 0 – 5 0 – 2.5 0 – 5 20 – 25
Merran McRae (Chair of the Trust) 50 – 55 0 0 – 5 0 – 5 0 – 2.5 0 – 5 50 – 55
Martin Wright (Non-executive Director) 15 – 20 100 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Cleveland Henry (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Kaneez Khan (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Frances Healey (Non-executive Director) 15 – 20 0 0 – 5 0 – 5 0 – 2.5 0 – 5 15 – 20
Zoe Burns-Shore (Non-executive Director) 5 – 10 0 0 – 5 0 – 5 0 – 2.5 0 – 5 5 – 10
Katy Wilburn (Non-executive Director) 10 – 15 0 0 – 5 0 – 5 0 – 2.5 0 – 5 10 – 15
Helen Grantham (Non-executive Director) 5 – 10 400 0 – 5 0 – 5 0 – 2.5 0 – 5 5 – 10

Cathy Woffendin and Helen Grantham were in Executive Director and Non-executive Director roles in 2023/24 but not in 2024/25 and so are included in the above table for comparative purposes only.

2.2.7 – Fair pay multiple

Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median, 25th percentile and 75th percentile remuneration of the organisation’s workforce.

Table 2.2K – Fair pay disclosure

2024/2025
Fair pay disclosure 25th Percentile Pay Ratio Median Pay Ratio 75th Percentile Pay Ratio
Total remuneration (£) £27,113 £37,338 £48,781
Salary component of total remuneration (£) £27,018 £37,257 £48,533
Pay ratio information 7.88:1 5.72:1 4.38:1
2023/2024
2023/24 25th Percentile Pay Ratio Median Pay Ratio 75th Percentile Pay Ratio
Total remuneration (£) £26,784 £36,253 £48,166
Salary component of total remuneration (£) £26,683 £36,140 £47,563
Pay ratio information 7.6:1 5.61:1 4.22:1

Total remuneration includes salary, non-consolidated performance-related pay and benefits-in-kind. It does not include severance payments, employer pension contributions and the cash equivalent transfer value of pensions.

For employees of the Trust as a whole, the range of remuneration in 2024/25 was from £41 to £324,851 (£19 to £208,401 in 2023/24).

The mid-point banded remuneration of the highest-paid director in the Trust in the financial year was £212,500 (£202,500 in 2023/24), a percentage change of 4.94% (2.53% change in 2023/24)

The average salary and allowance for all employees in the financial year was £53,312 (£50,207 in 2023/24), a percentage change of 6.18% (5.64% in 2023/24).

Reporting bodies are required to disclose the relationship between the remuneration of the highest paid director in their organisation and the median, 25th percentile and 75th percentile remuneration of the organisation’s workforce:

  • The ratio was 7.88 times (7.60 times in 2023/24) the 25th percentile remuneration of the workforce, which was £27,113 (£26,784 in 2023/24).
  • The ratio was 5.72 times (5.61 times in 2023/24) the median remuneration of the workforce, which was £37,338 (£36,253 in 2023/24).
  • The ratio was 4.38 times (4.22 times in 2023/24) the 75th percentile remuneration of the workforce, which was £48,781 (£48,166 in 2023/24).

In 2024/25, three substantive employees received remuneration in excess of the highest-paid director (1 in 2023/24). There are also 13 agency staff in excess of the highest-paid director (0 in 2023/24).

Remuneration for the highest paid substantive non-director was £227,050 (£209,442 in 2023/24). The highest paid agency non-director was £324,851 (2023-24 N/A).

The median, 25th percentile and 75th percentile salaries are calculated based on data that is generated from our payroll and e-rostering system. All staff that were employed by the Trust on 31 March 2025 are included in the calculation.

2.2.8 – Accounting policies

Accounting policies for pensions and other retirement benefits are set out in note 1.4 of the annual accounts in Part B of this Annual Report. Details of senior employees’ remuneration can be found in this Remuneration Report (senior employees for the purpose of the Remuneration Report are our executive and non-executive Board members).
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2.3 – The Accountability Report (Staff Report)

2.3.1 – Equality reporting

We believe in fairness and equality and above all value diversity and inclusion in all aspects of our work. This is demonstrated by our commitment to improving health and improving lives for our service users and staff.

Everyone who comes into contact with our organisation can expect to be treated with respect and dignity. We are committed to eliminating discrimination and to the fair treatment of everyone, taking into account all ‘protected characteristics’ under the Equality Act 2010 and the Human Rights Act 1998. If unfair discrimination occurs it will be taken seriously and it may result in formal action being taken against individual members of staff, including disciplinary action.

Over the last year we have delivered against the ambitions within our People Plan, informed by staff feedback from various sources. Our People Plan sets out our workforce equality commitments for 2024 to 2029 and a clear road map detailing how we will achieve these.

You can read our People Plan on Our Strategy page.

2.3.2 – Disability and employment

Our recruitment and selection procedures take full account of the requirements of the Equality Act 2010 and the associated public sector equality duties. This includes giving full and fair consideration to applicants with a disability or long-term health condition. Our refreshed People Plan details current and future actions and initiatives to respond to the immediate and longer-term needs of colleagues and to further develop the Trust as a healthy workplace in respect of both physical and psychological wellbeing.

We are also a Disability Confident Employer at level two, which demonstrates that we are positive about people with disabilities and support them to successfully attain and retain employment within the Trust.

We have supportive employment practices in place not only for those that we employ who have a disability, but for those who may become disabled whilst working for us. These include a comprehensive health and wellbeing service that includes access to an Employee Assistance Programme (which includes counselling), support for work and home related stress, flexible working arrangements and a bespoke Occupational Health Service. Our attendance procedures also take account of individual needs related to disability and provides for disability leave as a reasonable adjustment to support people to remain in work.

Our Wellbeing Assessments are embedded within our annual appraisal processes and procedure, to ensure that a recorded supportive discussion between a staff member and their manager takes place regularly. Reasonable adjustments to working environments have been undertaken, including home working and redeployment, and the purchase of specialised equipment, where appropriate. In addition, a career conversation process is incorporated within annual appraisal process to identify and action career development support and training needs. These procedures and services support the employment, retention and experience of disabled employees and the implementation of reasonable adjustments to take account of individual needs.

Our equality and diversity training package aims to raise awareness of a wide range of diversity issues, including disability, in order to minimise discrimination in all aspects of employment and is compulsory for all staff, with refresher training every three years. This approach helps ensure that our workforce is aware of current legislative and organisational requirements and best practice.

2.3.3 – Valuing our workforce

Our workforce is our most valuable asset and we recognise this by making a commitment to ensure they are well trained, well informed and are given every opportunity to contribute not only to the delivery of services but also to the development of these and other new services.

2.3.3.1 – Volunteers

The purpose of the Voluntary Services Department is to encourage the involvement of local people in the day to day running of our services. It has been another successful and busy year for our Voluntary Services and we would like to take this opportunity to recognise the incredible contribution by those who volunteer at the Trust.

There are currently 133 volunteers in the Trust who provide invaluable support to staff and service users. Of these, 63 have volunteered with the Trust for at least six months, with our longest serving volunteer having 24 years’ service. It is fantastic that we are retaining such a high percentage of volunteers beyond the six-month commitment that they make, showing that our volunteers are proud of the work they do and feel valued and well supported in their roles. This also reflects positively on the quality of working relationships between Trust staff and our volunteers.

Recruitment of volunteers has steadily increased since April 2024 and we welcomed 53 new volunteers into a variety of roles. There are a further 33 recruited volunteers who will be joining the Voluntary Services team over the coming months as soon as placements have been secured on our wards. Securing placements can be challenging despite making a concerted effort to raise awareness of our volunteers and provide information to staff. We strive to promote the value of volunteers and how they can enhance a services user’s journey while they are in our care.

2.3.3.2 – Staffside – working with the trade unions that represent our staff

Staffside is the elected body of the representative trade unions in our Trust.  We have two partnership forums for our Medical and Non-Medical workforce.  Our Joint Negotiation and Consultation Committee (JNCC) is established on behalf of our non-medical workforce and our Joint Local Negotiation Committee (JLNC) covers our medical workforce.  Both committees meet quarterly to discuss and question, on behalf of the wider union membership, any issues raised by the individual trade unions or by the Trust.  This committee enables our trade union colleagues to negotiate in partnership.  The JNCC and JLNC are the places where all issues raised at Staffside meetings are brought to the attention of management.

Staffside has many years of successful partnership working with the Trust. We have achieved this through the nationally recognised In Partnerships agreement.  Our Staffside Lead (partnership) works closely with the People and OD agenda and is a member of various governance groups where initiatives and challenges are discussed to ensure effective partnership working in the decision making of the organisation.

During the past year Staffside has contributed to the strategic agenda by contributing to the Trust’s Cost of Living and Civility and Respect programmes of work.  Staffside colleagues have helped to develop the Trust’s organisational change programmes within services and have a proactive and positive presence across the organisation.  In 2024/25 Staffside has:

  • actively encouraged staff to complete the annual staff survey which has enabled colleagues to have their voices heard.
  • collectively contributed to the work of the Cost of Living Task and Finish Group informing several initiatives across the Trust.
  • contributed effectively to the ongoing development of our local Civility and Respect Statement of Intent and the ongoing refresh of our Values and Behaviours Charter.
  • successfully worked in partnership with the People and OD Directorate and its managers to support staff going through organisational change and workforce transformation.
  • contributed to the job evaluation process under Agenda for Change to ensure fairness and equity in pay banding.
  • continued to support colleagues who are redeployed to minimise anyone at risk of redundancy
  • contributed to the review and development of employment procedures, namely the review and update of Wellbeing and Attendance Policy and Disciplinary Policy. The review of the Trust Disciplinary Policy aimed to prevent employees escalating unnecessarily into a formal process, thereby improving employee relations within the Trust.

Staffside also provides information and advice to colleagues through the development of an internal intranet page on Staffnet. They can also be contacted by emailing Staffside.

The following tables show the Trade Union Facility Time which is required to be reported under the Trade Union (Facility Time Publication Requirements) Regulations 2017.

Table 2.3A – The number of employees who were relevant union officials employed during 2024/25
Number of employees who were relevant union officials during the relevant period Full-time equivalent employee number
7 6.60
Table 2.3B – Percentage of time spent on facility time – The number of employees who were relevant union officials employed during 2024/25 and the percentage time of their working hours spent on facility time
Percentage of time Number of employees
0% 0
1-50% 7
51-99% 0
100% 0
Table 2.3C – Percentage of pay bill spent on facility time during 2024/25
Total cost of facility time £68,309.18
Total pay bill £202,099,852
Percentage of the total pay bill spent on facility time 3.38%
Table 2.3D – Paid trade union activities during 2024/25
Time spent on paid trade union activities as a percentage of total paid facility time hours 6.70%

2.3.3.3 – Promoting the wellbeing of our workforce

The Workforce Committee, chaired by the Wellbeing Guardian (who is a Non-executive Director) holds the Board accountable for matters relating to staff wellbeing. The committee regularly reviews workforce data on Occupational Health, the Employee Assistance Programme (EAP), CrISSP (Critical Incident Support Pathways) Ward Wellbeing Buddy programme, Menopause and Sexual Safety.

In October 2023, the Trust signed up to the NHS Sexual Safety Charter in collaboration with key partners across the healthcare system. Through this committed to taking and enforcing a zero-tolerance approach to any unwanted, inappropriate and/or harmful sexual behaviours within the workplace, and to the ten core principles of the charter. A cross organisational task and finish group has been established to implement activity against the commitments.

Through 2024/25 the Health and Wellbeing Team delivered several wellbeing awareness sessions with teams, alongside a comprehensive programme of roadshows to eight of our main sites, where we engaged with staff ensuring awareness of the extensive support package available. A line managers guide to wellbeing support was also launched to ensure managers had up to date knowledge and access to all available services.

The Health and Wellbeing Team delivered a package of support for financial wellbeing including the financial support fund, sessions on ‘Getting the most out of your pension’ and providing staff access to Simply Health.

The Critical Incident Staff Pathway (CrISSP) usage continued to increase with 108 sessions being held in 2024/25 and 496 staff individually supported. This support ensures local teams are provided with more immediate wellbeing support following an incident or untoward event. This support was provided alongside the Ward Wellbeing Buddies which provided drop-in sessions for staff for wellbeing support at 11 of our wards.

In 2024/25 we trialled mindfulness-based cognitive therapy (MBCT) for staff, which was provided through virtual headsets that were distributed across the organisation. This aim of this initiative was to alleviate the symptoms of stress and burnout in staff and the evaluation showed a positive impact on mood for those using the headsets regularly. The Health and Wellbeing Team also launched Wellbeing Champions in June 2024, delivering in house training to 46 members of staff. Our ambition is to have a champion within every team.

All health and wellbeing offers, events and updates are shared through our monthly Wellbeing Wednesday newsletter.

2.3.4 – Staff communications and engagement

The Communications Team engages staff across the Trust mainly through corporate communications channels such as Staffnet (our intranet), the weekly Trustwide bulletin, our monthly Chief Executive all staff huddles, leadership and strategic priorities blogs, and a range of other activity which is done in partnership with key internal stakeholders, including the individual teams within our People and Organisational Development Directorate.

In 2024 the Communications Team launched a new staff intranet called Staffnet 365. This new platform is integrated with Microsoft 365 and is now available on any device, from any location, 365 days a year. It features a dedicated staff health and wellbeing microsite and a People Hub to support staff through the full employee journey.

In November 2024, the Board of Directors ratified the Trust’s new five-year strategy, ‘Improving the Health and Lives of the Communities We Serve 2025-2030’. The Trust’s Communications Team played a central role in its development and is leading the ongoing socialisation of the strategy.

The Team continued to support staff wellbeing with the production and distribution of the monthly ‘Wellbeing Wednesday’ newsletter. It is designed to promote health and wellbeing policy updates, new resources, events and support offers that are relevant each month. Analytics show it has a high readership of over 50% of staff across the organisation.

The team prioritises People Resourcing and Retention and during the year focused on launching the values-based recruitment programme across the Trust, as well as apprenticeships and flexible working.  There was also a focus on Equality, Diversity and Inclusion with the promotion our staff networks, our cultural inclusion ambassadors and celebrating National Inclusion Week.

Other key achievements during 2024/25 included:

  • Launching a new brand identity for the Trust which featured the strapline ‘Leading the way in mental health, learning disability and neurodiversity services’
  • Revolutionising our flagship weekly Trustwide bulletin, with a new streamlined structure, submission process and brand refresh – with analysis showing it is now read by over 80% of the organisation
  • Supporting our Community Mental Health Transformation programme with the launch of our three early implementor sites in Leeds
  • Playing a leading role in the successful public consultation to repurpose our Parkside Lodge unit for a new clinical service to move into during 2025/26
  • Supporting the process to develop and socialise other strategic plans including our Improving Health Equity Strategic Plan and our Green Plan
  • Hosting our Annual Members’ Meeting in July 2024 which incorporated our Annual General Meeting and a successful celebration event featuring staff and service user stories.

2.3.4.2 – Improving Culture: Our LYPFT People Plan

At the start of 2024 the Trust refreshed its People Plan to ensure that it was fit for purpose and able to deliver our ambition of leading the way in mental health, learning disability and neurodiversity care.

This meant that we also refreshed our ambition and re-launched a three-year People Plan covering 2024-2027. We continue to measure the delivery of this plan and review its impact every three months to ensure it is fully delivering on all of the Trust’s key workforce ambitions. This has been collaboratively developed in consultation with colleagues across the Trust against other strategic intentions and also reviewed in line with the NHS Workforce Plan.

We know that leaders play a key role in developing our culture to create positive and healthy working environments for our people. Work to develop our leaders to lead collectively and inclusively in line with our Trust values has been continuing during 2024/25. The Trust continues to support the ongoing programme of development for managers with our Manager 360 development programme and our Collective Leadership senior development programme which focusses on the senior cohort of managers within the organisation addressing the need to lead collectively.

Our People Plan covers a variety of workforce initiatives and proactively implements these across the Trust. Good progress has been made in our Civility and Respect programme of work. The programme is led by a task and finish group of Trust stakeholders who review the Trust priorities and activities with an aim of improving respect and civility in the workplace. The Trust has successfully launched its Civility and Respect Statement of Intent and has refreshed the Values and Behaviour Charter. Work has also focused on two development resources which will contribute to the improvement of culture in service lines. The first resource is a cultural competence development programme and the second is a development session for teams on developing a positive workplace culture. Both development programmes are in the pilot phase with evaluation information expected in April 2025.

The Trust has also successfully implemented a mediation service with nine mediators being trained in 2024. This work is within the Civility and Respect programme of work and focuses on the Trust’s approach to a ‘just and learning culture’ resolving concerns early for colleagues in the workplace when they arise.

2.3.4.3 Staff experience and engagement

Our staff experience at work is crucially important both to the health and welfare of our staff and to the quality of care we provide to our service users. Our staff are best placed to say when progress has been made or if there are areas for improvement. By amplifying our colleague voice at our Trust, we work together to take positive action to recognise, value and appreciate everyone.

The People Promise provides a framework for understanding and measuring employee experience across the Trust via the NHS National Staff Survey. It enables teams and departments to track progress and take action to improve.

Through the use of local and national listening tools, our priority is to consistently understand and enhance employee experience, to make the Trust the best place to work and to provide the best possible care for the communities we serve.

2.3.5 – Our staff survey

The NHS staff survey is conducted annually. The survey questions continue to align to the seven elements of the NHS ‘People Promise’, including two additional themes of engagement and morale. All indicators are based on a score out of ten for specific questions with the indicator score being the average of those.

The response rate to the 2024/25 survey among trust staff was 49.5% (compared to 50.19% in 2023/24).

Scores for each indicator together with that of the survey benchmarking group (Mental Health & Learning Disability Trusts and Mental Health, Learning Disability & Community Trusts) are presented below.

Table 2.3E – Staff survey results

Indicators
(‘People Promise’ elements and themes)		 2024/25 Trust score 2024/25 Benchmarking group score 2023/24 Trust score 2023/24 Benchmarking group score 2022/23 Trust score 2022/23 Benchmarking group score
We are compassionate and inclusive 7.51 7.55 7.58 7.58 7.56 7.54
We are recognised and rewarded 6.34 6.35 6.48 6.41 6.36 6.28
We each have a voice that counts 7.00 6.94 7.07 7.01 7.03 6.97
We are safe and healthy 6.47 6.40 6.45 6.38 6.19 6.24
We are always learning 5.76 5.93 5.87 5.93 5.54 5.72
We work flexibly 7.04 6.83 7.11 6.84 6.98 6.75
We are a team 7.06 7.15 7.14 7.18 7.15 7.10
Staff engagement 7.01 7.07 7.12 7.11 7.01 7.05

The following chart displays the Trust’s People Promise element and theme scores for 2024/25 against the benchmark group and includes the best and worst scores from the group.

A bar chart displaying scores for various People Promise elements, themes, and sub-scores on a 0–10 scale. The categories include "We are compassionate and inclusive," "We are recognised and rewarded," "We each have a voice that counts," "We are safe and healthy," "We are always learning," "We work flexibly," "We are a team," "Staff Engagement," and "Morale." Each category shows bars representing the organization's score, best result, average result, worst result, and the number of responses.

Caption: Bar chart illustrating the scores for different People Promise elements on a 0–10 scale. The chart compares the organisation’s score with the best, average, and worst results across categories such as compassion, recognition, safety, learning opportunities, flexibility at work, teamwork, staff engagement, and morale.

For the 2024/25 Survey year, the Trust reported its highest number of actual responses, with 1,637 staff participating, 68 more than in the 2023/24 Survey. A significant engagement and communications campaign was conducted to engage leaders and staff across the Trust with the aim of increasing participation.

When comparing our results to the national average benchmarking group, we performed better in three People Promise elements: ‘We each have a voice that counts’, ‘We are safe and healthy’, and ‘We work flexibly’. However, we have seen declines in the remaining elements and in the theme of Staff Engagement, with the largest difference compared to the benchmarking group in the element ‘We are always learning’ (-0.17). The theme of Morale matches the benchmark group score.

The 2024/25 survey results have remained largely unchanged and are in line with the national picture. We have seen positive results at the question level regarding staff understanding their work responsibilities, feeling trusted to perform their job, and believing their role has a positive impact on service users. However, results were not as strong as the previous year for questions related to teamwork, career development, and feeling valued and involved.

Staff feedback from the survey highlights that there is still work to be done and lessons to be learned from less favourable results. The People Promise elements that have seen the biggest decrease are: ‘We are recognised and rewarded’ (-0.14), ‘We are always learning’ (-0.11), and the theme of ‘Staff engagement’ (-0.11). Additionally, one Workforce Race Equality Standard (WRES) Indicator (Indicator 8) is lower than the benchmarking group, along with two Workforce Disability Equality Standard (WDES) Indicators (Metric 4a and Metric 5). These results are shared widely so that consideration of action to support change can be delivered at a local level.

To support our teams, the Trust continues to promote and recommend intention plans to facilitate a simplified version of local action planning. The intention plan was developed to ask teams and services to reflect on their local results and commit to doing just one thing differently that could improve the experiences of staff working in that area. Over the past couple of years, we have observed a continuing trend, when an intention plan has been completed, the team is more likely to increase its response rate the following year. This supports the feedback cycle and places teams at the heart of meaningful change.

Throughout 2024/25 work continued at a strategic level to improve colleague experience across the Trust, with a key focus on reward and recognition:

  • In January 2024, we launched our new Reward and Recognition platform, Spotlight. The platform allows staff to send meaningful, in the moment recognition with Ecards and has supported a range of appreciation campaigns including NHS Heroes, where staff are nominated and acknowledged by their peers.
  • There has been a continued emphasis on recognising and rewarding excellence with Individual of the Month and Team of the Month awards. Both awards highlight the valuable contributions of staff and demonstrate how colleagues bring our Trust Values to life.
  • To foster a culture of wellbeing, we have relaunched our Wellbeing Champion network. By training staff to advocate for our wellbeing initiatives, we can significantly enhance engagement and ultimately improve overall wellbeing.
  • We have established groups continuing to focus on Civility and Respect to improve the experience of staff regarding incidences of bullying, harassment or abuse, physical violence, and discrimination. We are using deep dives into Staff Survey data across protected characteristics to help inform these plans.

2.3.5.1 Future priorities and targets

An analysis of our Staff Survey results provides us with a basis for determining the main areas to focus on when developing our key areas for action in 2025/26.

We will continue to build on our engagement and communications campaign to increase participation in the Survey.

For the fourth year we will be encouraging the completion of intention plans as this has demonstrated a proven link to an increased response rate, where action is driven at the local level. The People Engagement Team are partnering with leaders across the Trust to support the development of their plans. Intention plans will be submitted in June 2025 and presented to the Workforce Committee in August 2025.

2.3.6 – How we involve our staff in understanding performance

2.3.6.1 – Financial Performance

Our performance information is shared with our Board, our Council of Governors and performance dashboards have been created at team and service line level, in order that we can share performance information with our staff.

2.3.6.2 – Contractual and regulatory performance

We continue to expand the range of timely and accessible operational dashboards for service managers via CareDirector and our business intelligence (BI) tool, Echo. These dashboards provide teams with the tools to manage patient care pathway activity and to monitor data integrity. Additionally, we continue to support the Trust’s new approach to performance management by presenting the Key Performance Indicator data that services need to better manage the performance and quality of their services – including an increased focus on our data through the lens of quality, assessed via the Trust’s measure of quality (the STEEEP framework, which stands for Safe, Timely, Effective, Efficient, Equitable, and Patient-centred care). We continue to pro-actively engage with staff in each area (including service managers and clinical leads) to promote the use of new dashboards to enable discussion of performance across a range of topics including improved service delivery and quality improvement plans.

Overall performance against our contracts is monitored by the Finance and Performance Committee, which has tracked the continued impact of pressures and industrial action on performance, data quality and risk.

We continue to embed our definition of quality (the STEEEP framework) into our routine reporting at all levels of the organisation. This, in tandem with the consolidation of our reporting and improvements made to our BI tool, aims to simplify our approach, lead to improved levels of engagement from staff and others in the quality agenda, and build up a body of knowledge through the organisation on what good quality looks like.

2.3.7 – Sickness absence

Details of the Trust’s sickness absence data can be found on the NHS Digital website.

The overall average sickness absence rate between April 2024 to March 2025 was 5.97% which is a decrease when compared with the previous years’ absence which was 6.49%. Sickness absence rates followed a seasonal pattern with significant high points between August and September and January and February, with corresponding low points in April and June and November and December.

The latest figures available from NHS Digital as at December 2024 show that the overall sickness absence rate for England was 5.7% which is lower than the Trust’s position of 5.97% for March 2025. Comparison with other Mental Health Trusts shows that the average of all reporting Mental Health Trusts is 6.2% compared to the Trust’s position of 6.57% in the same period (December 2024). Regional benchmarking indicates that the Trust’s sickness absence figure of 6.57% is lower than the other Mental Health and Learning Disability Trusts in the Northeast & Yorkshire where their average is 6.77% in December 2024.

The long-term sickness absence rate decreased from 4.03% to 3.37% on average with short-term absence increasing slightly to 2.07% on average of overall absence (an increase from 2.01% in the previous year).

The top three service areas with the highest overall absence rate in 2024/25 were the Adult Acute Services (8.21%), Forensic Services (7.74%), and Children and Young People’s Services (7.59%). The People and Organisational Development Team is actively working with service areas to address those teams with a high prevalence of sickness absence. The Wellbeing & Attendance Group reviews absence indicators and identifies where there may be hot spots or areas for improvement alongside suggesting amendments to policies and processes.

The professional group with the highest sickness absence in the previous 12 months was Additional Clinical Services, which incorporates healthcare support roles, which has increased from 7.97% in 2023/24 to 8.10% in 2024/25. Nursing and Midwifery also increased from 5.35% to 6.26% and is the largest staff group in the Trust. The absence rate for Allied Health professionals was 6.19% in 2024/25.

Our top reason for sickness absence continues to be mental health related absences (Stress and Anxiety) at 39.1% of overall absence which is an increase when compared to the previous year for which it was 37% of overall absence. This is a consistent position compared the rest of the NHS where anxiety/stress/depression/other psychiatric illnesses is consistently the most reported reason for sickness absence. The second top reason for absence in 2024/25 was Cough, Cold, Flu at 12.3% and Musculoskeletal (MSK) related absence at 7.7%. These are the areas where we are focusing our efforts to support colleagues and improve attendance overall.

The tables below show our sickness absence rate during 2024/25 and present some statistics around the number of days lost due to sickness absence.

Table 2.3F – Sickness absence

Line graph titled "LYPFT Sickness Absence April 2023 – March 2025 (%)" showing monthly sickness absence percentages for three years: 2022/23 (blue line), 2023/24 (red line), and 2024/25 (green line). The x-axis spans April to March, and the y-axis ranges from 0.00% to 8.00%.
Caption: Line graph comparing monthly sickness absence rates at LYPFT across three years (2022/23, 2023/24, and 2024/25). The chart highlights trends and fluctuations in absence percentages from April to March.

Table 2.3G – Sickness absence percentage

Month 2022/23 2023/24 2024/25
April 6.37% 5.48% 5.36%
May 5.29% 5.58% 5.51%
June 6.12% 5.55% 5.77%
July 6.61% 6.07% 6.07%
August 6.30% 6.09% 6.16%
September 5.99% 6.27% 5.97%
October 5.92% 6.80% 6.06%
November 6.54% 6.28% 6.13%
December 7.33% 6.18% 6.59%
January 5.92% 6.94% 6.58%
February 5.80% 5.68% 5.99%
March 5.96% 5.39% 5.44%

Table 2.3H – Long Term Sickness Absence percentage

Line graph titled "LYPFT Long-Term Absence April 23 – March 25 (%)" showing monthly long-term absence percentages for two years: 2023/24 (darker blue line) and 2024/25 (lighter blue line). The x-axis spans April to March, and the y-axis ranges from 0.00% to 5.00%.
Caption: Line graph comparing long-term absence rates at LYPFT across two years (2023/24 and 2024/25). The chart tracks monthly trends in long-term absence percentages from April to March.

Table 2.3I – Short Term Sickness Absence

Line graph titled "LYPFT Short-Term Absence April 23 – March 25 (%)" showing monthly short-term absence percentages for two years: 2023/24 and 2024/25. The x-axis spans April to March, and the y-axis ranges from 0.00% to 3.00%. Two lines represent each year, with a legend indicating which line corresponds to which year.
Caption: Line graph comparing short-term absence rates at LYPFT across two years (2023/24 and 2024/25). The chart illustrates monthly trends in short-term absence percentages from April to March.

Table 2.3J – Sickness absence as reported in the FTCs

  • Figures Converted by DH to Best Estimates of Required Data Items.
  • Statistics Produced by NHS Digital from ESR Data Warehouse.
Average FTE 2024 Adjusted FTE days lost to Cabinet Office definitions FTE-Days Available FTE-Days Lost to Sickness Absence Average Sick Days per FTE
3,027 40,777 1,104,898 66,149 13.5

All absence data is recorded internally using the functionality of the Health Roster system and absence data is regularly reported through our Electronic Staff Record and shared with the People and Organisational Development Team and service lines to identify hotspots and particular trends.

2.3.8 – Occupational health service

We continue to share our Occupational Health Service with South West Yorkshire Partnership NHS Foundation Trust. It remains a nurse-led service created to meet the specific needs of colleagues in mental health, learning disability and community services. The team now provides an overall occupational health service for 20,000 employees in the region and continues to operate service level agreements for external contracts.

During 2024/25 our Occupational Health Service provided a general advice line for managers and colleagues from Monday to Friday, with support from Clinic Nurses, a Physiotherapist, Occupational Therapists, and a Mental Health Nurse. The increased provision of more specialist roles provided by this service demonstrates the wide variety of need and usage by our workforce.

The Occupational Health Service transitioned to a new computer system which will provide our managers with an easier and more streamlined process of referral. During the reportable time the old system was in place (April – November), the highest usage of the occupational health service was for physiotherapy appointments with 843 booked and management referrals to the occupational health service with 728 appointments booked. They also provided staff with 58 health check appointments.

The service also provided several specialist services including menopause awareness sessions, line management training on writing a referral, training for our Health and Wellbeing Champions, and bespoke team support to teams identified through the Wellbeing and Attendance Group for additional support.

2.3.9 – Health and safety

Several changes have taken place in 2024/25 within the Health and Safety Team. A new Head of Health and Safety was appointed in June 2024 alongside the recruitment of two new Health and Safety Advisors. They have been supported by the Deputy Director of Estates & Facilities.

A review of the terms of reference and associated governance was undertaken and completed for the Trust’s Health and Safety Committee to ensure that the reporting was fit for purpose and effective. This instigated the establishment of further, broader relationships across the Trust to ensure that health and safety was truly capturing as much relevant information, and offering as much support, as possible.

The annual health and safety audit programme continued in 2024/25. “Outstanding audit actions” is now an established standing agenda item on monthly site meetings to ensure any outstanding actions are completed in a timely manner with these KPIs reported at local meetings up to relevant Trust committees.
The Trust’s lone working systems received a significant upgrade during 2024/25, with a view to the longer term safety of our workforce, with 1000 mobile application licences procured. Lone working staff identified as being ‘at risk’ from their work activities now have immediate 24/7 access to a dedicated call centre specialising in supporting services and staff at immediate risk in a safety incident.

The Health and Safety Team has further strengthened the Trust’s partnership working ethos and now takes a leading role across the Yorkshire & Humberside Region, working with other Trusts to share information and learn from safety related incidents, initiatives and developments in legislation. Collaborative working also extends to supporting the Health & Safety Executive’s ‘Working Well Together’ initiative, both nationally and within the Yorkshire & Humberside region, which provides information and support to small and medium enterprises to help make it easier for the communities served and the people at work to achieve their goals.

Given some of the challenges regarding Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) over previous years, an updated procedure has been drafted with plans for this to be signed off in 2025/26.

Commercially, the Trust’s Health & Safety Team was awarded the opportunity to support Spectrum Community Health CIC with their health, safety and environmental requirements on a consultancy basis which provides a modest income to the Trust.

The content of this update captures some key components of the Health and Safety Annual Work Plan which has been successful but equally provides a platform to allow further focus and improvement in 2025/26.

2.3.10 – Counter fraud

During 2024/25 the Local Counter Fraud (LCFS) Specialist Service was provided by NHS Audit Yorkshire.  Audit Yorkshire specialises in all aspects of internal audit and counter fraud work, primarily across the NHS but also the public, corporate and not for profit sectors.  Audit Yorkshire has a team of accredited and experienced LCFS personnel.

In January 2021 the NHS Counter Fraud Authority (NHSCFA) issued the NHS Requirements which provided detailed information on how the Government Functional Standard 013 Counter Fraud must be applied across the NHS. The requirements outlined an organisation’s corporate responsibilities regarding counter fraud and the key principles for action. For 2024/25 the LCFS produced an Annual Counter Fraud Plan aligned to the standards.

There are 12 components within the Functional Standard which are sub divided as:

  • Governance – which outline how the organisation supports and directs counter fraud, bribery and corruption work, undertaken to create a strategic organisation wide response when combatting fraud bribery and corruption.
  • Counter Fraud Bribery and Corruption Practices – which outline the organisations operational counter fraud activities undertaken during the year when detecting and combatting fraud.

The Trust’s Audit Committee reviews and approves the Annual Counter Fraud Plan identifying the actions to be undertaken to promote a counter-fraud culture, prevent and deter fraud and investigate suspicions of fraud. The LCFS also produces an annual report for the Trust and regular progress reports for the review and consideration of the Chief Financial Officer and the Audit Committee.

The Chief Financial Officer for the Trust is proactively and demonstrably responsible for tackling fraud, bribery and corruption and the LCFS regularly attends the Audit Committee. The Trust also has a nominated Counter Fraud Champion (CFC) to support the work of the LCFS. The CFC is also the Trust’s Freedom to Speak up Guardian.

The Trust’s counter fraud arrangements are currently compliant with the NHS Requirements published by the NHSCFA. These arrangements are underpinned by the appointment of the LCFS, the Counter Fraud, Bribery and Corruption Policy and the nomination of the Chief Financial Officer as the Executive Lead for Counter Fraud.

The LCFS completes an annual self-assessment of compliance against the NHSCFA’s standards, which is reviewed and approved by the Chief Financial Officer and Chair of the Audit Committee prior to submission to the NHSCFA. The 2023/24 assessment for the Trust was completed with reference to the NHS Requirements. The assessment was submitted in May 2024 with an overall rating of Green. The return was also shared with Audit Committee members within the 2023/24 Annual Counter Fraud Report.

The LCFS will be providing a response to the Counter Fraud Functional Standard Return on behalf of the Trust in May 2025. This will look at the Trust’s compliance to the NHS Requirements within the 2024/25 financial year and will be reviewed by the Chief Financial Officer and the Chair of the Audit Committee prior to submission.

The Trust participates in the National Fraud Initiative (NFI). The NFI is a sophisticated data matching exercise, which matches electronic data within and between participating bodies to prevent and detect fraudulent and erroneous payments from the public purse. This includes NHS bodies, local authorities, government departments and other agencies and a number of private sector bodies.

During 2024/25 the LCFS received allegations regarding possible fraudulent behaviour and investigated the matters accordingly whilst working in conjunction with the relevant departments throughout the Trust where appropriate. As a result of the investigations the LCFS undertook, no criminal action was taken in any of the reported matters.

The LCFS worked closely with key departments within the Trust during 2024/25 and disseminated local and national fraud alerts to departments in order to prevent fraud at the Trust.

2.3.11 – Average staff numbers

Table 2.3K – Average staff numbers for 2024/25

Average number of employees
(Whole Time Equivalent basis)		 Permanent (Number) Other (Number) Total Number
(2024/25)		 Total Number
(2023/24)
Medical and dental 234 20 254 237
Administration and estates 792 21 813 796
Healthcare assistants and other support staff 721 300 1021 1,020
Nursing, midwifery and health visiting staff 822 62 884 839
Scientific, therapeutic and technical staff 465 4 469 425
Social care staff 50 0 50 43
Total average numbers (2023/2024) 3,360
Total average numbers Permanent (Number) Other (Number) Total Number
(2024/25)		 Total Number
(2023/24)
Of which:
Number of employees (WTE) engaged on capital projects		 3,084 407 3,491 0

2.3.12 – Gender profile of our Trust

Table 2.3L – The gender profile for the Trust as at 31 March 2025

Group Number male Number female Total
Directors 4 9 13
Senior managers (Band 8 and above) 197 380 577
Employees 700 2069 2769

2.3.13 – Gender pay gap information

The gender pay gap shows the differences in average pay between men and women. The gender breakdown of our total workforce is 75% female and 25% male. In the 2024/25 gender pay gap reporting period the Trust’s mean pay gap figure was 8.1%, which is a reduction on 2023/24 when it was 10.5%.

We continue to undertake actions to address the gender pay gap through promoting opportunities for flexible working, shared parental leave, career progression, promotion, and leadership development opportunities.

Details of the Trust’s gender pay gap data can be found on our Equality and Diversity page and the and Cabinet Office website.

2.3.14 – Analysis of staff costs

Table 2.3M – Analysis of staff costs for 2024/25

Average number of employees (Whole Time Equivalent basis) Permanent (£000) Other (£000) Total £000 (2024/25)
Salaries and wages 128,861 19,539 148,400
Social security costs 14,581 0 14,581
Employer’s contributions to NHS pensions 18,053 0 18,053
Pension cost – employer contributions paid by NHSE on provider’s behalf (9.4%) 11,871 0 11,871
Apprenticeship Levy 709 0 709
Agency staff 0 8,424 8,424
Employee benefits expense 174,075 27,963 202,038
Of which: Charged to capital 0 0 (38)
Of which: Recharged to income 0 0 (139)
Total employee costs 174,075 27,963 201,861

2.3.15 – Off-payroll engagements

The Trusts policy in relation to off payroll engagements includes:

Off-payroll arrangements are those where individuals, either self-employed or acting through a personal service company, are paid gross. While off-payroll arrangements may sometimes be appropriate for those engaged on a genuinely interim basis, they are not appropriate for those in management positions or those working for a significant period with the same employer.

The Trust acknowledges that off payroll engagements may sometimes be appropriate and beneficial. It is therefore important that these engagements are transparent and are open to scrutiny in the event of challenge.

Off payroll engagements should only be made via the Procurement Team, with an authorised requisition and purchase order in place. Under no circumstances should Trust employees engage with any agency or individual (Personal Service Company) directly without consultation with the Procurement Team.

In all circumstances appropriate contracts and/or framework agreements should be in place between the Trust and either the individual, agency or personal service company. All contracts and/or framework agreements should include a clause giving the Trust the right to seek assurance in relation to income tax and national insurance.

In addition, the appointing manager is required to undertake a risk assessment as to whether or not assurance needs to be sought that the individual is paying the right amount of tax and national insurance. This applies to all circumstances and a proforma for this is included in the policy.

Table 2.3N – Length of all highly paid off-payroll engagements (for all highly paid off-payroll engagements as of 31 March 2025, greater than £245 per day)

Number of existing engagements as of 31 March 2025 20
Of which: The number that have existed for less than one year at the time of reporting 11
The number that have existed for between one and two years at time of reporting 2
The number that have existed for between two and three years at time of reporting 3
The number that have existed for between three and four years at time of reporting 1
The number that have existed for four or more years at time of reporting 3

Table 2.3O – Off-payroll workers engaged at any point during the financial year (for all off-payroll engagements between 1 April 2024 and 31 March 2025, for more than £245 per day)

Number of off-payroll workers engaged during the year ended 31 March 2025 42
Of which: The number not subject to off payroll legislation 42
The number not subject to off-payroll legislation and determined as within the scope of IR35 0
The number not subject to off-payroll legislation and determined as out-of-scope of IR35 0
The number of engagements reassessed for compliance or assurance purposes during the year 0
Of which: 0
Of which, the number of engagements that saw a change to IR35 status following review 0

Table 2.3P – Off-payroll board member/senior official engagements (or any off-payroll engagements of board members, and/or, senior officials with significant financial responsibility) between 1 April 2024 and 31 March 2025

Number of off-payroll engagements of board members, and/or, senior officials with significant financial responsibility, during the financial year. 0
Number of individuals that have been deemed “board members and/or senior officials with significant financial responsibility” during the financial year. This figure should include both off-payroll and on-payroll engagements. 13

2.3.16 – Staff exit packages

These reporting requirements cover the total costs of exit packages agreed in the year. They include payments under the Civil Service Compensation Scheme (CSCS), payments under any other compensation schemes where applicable, e.g. other Non-departmental Public Bodies (NDPBs) and any other payments made.

Exit packages for Board members are included above with further detail in the Directors’ Remuneration Report. There was no exit package agreed relating to a Board member in 2024/25 (0 in 2023/24).

The Remuneration Report provides specific details of exit payments payable to individuals named in that report.

Table 2.3Q – Staff exit packages

Exit package cost band Number of compulsory redundancies Number of other departures agreed Total number of exit packages by cost band
Less than £10,000 1 (1) 7 (4) 8 (5)
£10,001 – £25,000 3 (0) 12 (1) 15 (1)
£25,001 – £50,000 1 (0) 1 (0) 1 (0)
£50,001 – £100,000 0 (0) 0 (0) 0 (0)
£100,001 – £150,000 1 (0) 0 (0) 1 (0)
£150,001 – £200,000 0 (0) 0 (0) 0 (0)
Greater than £200,000 0 (0) 0 (0) 0 (0)
Total number of exit packages by type 6 (1) 20 (5) 26 (6)
Total resource cost (£000) 230 (8) 241 (33) 471 (41)

Note: Figures in brackets relate to 2023/24.

2.3.18 – Expenditure on consultancy

Details of our expenditure on consultancy can be found in Note 5 of the Annual Accounts in Part B of Annual Report.

2.3.19 – Mental Health Act Managers

2.3.19.1 – The role and remit of the Mental Health Act Managers

Mental Health Act Managers (MHAMs) are members of the public, appointed by the Board of Directors, together with non-executive directors who are able to act in this role.  Their key responsibilities are to:

  • Review the detention of service users who are either detained under the Mental Health Act or who have been placed on Community Treatment Orders (CTO)
  • Discharge those service users who no longer meet the criteria to be detained or are subject to a CTO.

Providing assurance to the Mental Health Legislation Committee is the Mental Health Act Managers Forum.  The Forum is chaired by a non-executive director and/or the lead Mental Health Act Manager to ensure a direct link to the Board of Directors in accordance with the Mental Health Act Code of Practice.  This seeks to provide a forum for communication between the committee, the Mental Health Act Managers and the officers of the Trust.  It provides a mechanism for assurance on, the robustness of arrangements in place for the Trust to meet its duties in respect of the Mental Health Act 1983.

In 2024/25, the Mental Health Act Managers Forum was chaired by Kaneez Khan, Non-executive Director, Viv Uttley, Lead Mental Health Act Manager and Deputy Chair of the Forum and Noel Devine who took over as Deputy Chair of the MHAMs Forum in August 2024. The Forum met four times, on 16 April 2024, 17 July 2024, 18 October 2024 and 4 February 2025. All meetings were held remotely via MS Teams.

2.3.19.2 – Mental Health Act Managers who have served in 2024/25

We currently have 36 acting Mental Health Act Managers, and the table below shows those people who have acted in this capacity during 2024/25. We had five MHAMs leave the panel during 2024/25, three due to fixed term contracts, one due to resignation and one panel member who sadly passed away. There are sufficient panel members to meet legislative requirements.

Table 2.3S – Mental Health Act Managers during 2024/25

Mental Health Act Managers during the period 1 April 2024 – 31 March 2025:

  • Harold Kolawole
  • Sharon Borrett
  • Devon McCroakam
  • Gillian Nelson
  • Dianne Graham
  • Katherine Burdett
  • Susan Smith
  • Naveed Riaz
  • Lorraine Comley
  • Paul Yeomans
  • Roger Grasby
  • Noel Devine
  • Nick Asiedu
  • John Devine
  • Dipak Patel
  • Natasha Campbell
  • Michael Hartlebury
  • Nicole Quelch
  • Laura Haggett
  • Trevor Jones
  • Joseph Ramage
  • Julie Horne
  • Andrea Kirkbride
  • Juan Souto
  • Angela Raby
  • Viv Uttley
  • Valerie Zwart
  • Anne Rice
  • Wasim Khan
  • Geraldine Langan
  • Abi Kolawole
  • Kathy Bayliss
  • Masuma Begum
  • Michelle Pearson
  • Maria Clark
  • Bethany Holden
  • Bernadette Addyman
Table 2.3T – Leavers of the Mental Health Act Managers Panel during 2024/25

Leavers of the Mental Health Act Managers panel during the period 1 April 2024 to 31 March 2025:

  • Rebecca Casson – End of fixed term contract
  • Graham Martin – End of fixed term contract
  • Shamaila Qureshi – End of fixed term contract
  • Alex Sangster – Resigned
  • Naveed Riaz – Deceased
Table 2.3U – Non-executive directors acting as Mental Health Act Managers during 2024/25

Non-executive directors also acting as Mental Health Act Managers during the period 1 April 2024 to 31 March 2025: Not applicable.

We are appreciative of the time and commitment that Mental Health Act Managers acting as Mental Health Act Managers have given this year. Once again, we wish to thank our Mental Health Act Managers for their dedication and the skill they apply when undertaking this vital role.

2.3.20 – Diversity and inclusion policies

Our commitment to establishing a positive culture which promotes diversity and inclusion through narrowing inequality gaps, openly addressing discrimination and ensuring that all our people have a voice, is set out in our People Plan 2024 – 2027, which can be found on the Our People Plan page.
In 2024/25 we have continued to build upon work to develop an inclusive and compassionate leadership community through the delivery of the collective leadership programme for our senior leaders. We have expanded our 360 Manager programme, which is a comprehensive self-assessment and development programme designed to develop our managers and those aspiring to move into management. This programme focuses on diversity, inclusion and inclusive behaviours across all elements. To further strengthen collective accountability, we have also introduced equality and diversity objectives for our Board of Directors.

Our recruitment and selection policy takes a values-based approach with a focus on the development of fair and inclusive processes to support a representative workforce at all levels and to target under-representation. We have also developed an accessible step by step recruitment guide to support candidates at every level of their recruitment journey. In addition, we have a widening participation strategy, which includes a supportive and more tailored recruitment process that supports our aspiration of ensuring we have a representative workforce at all levels.

2.3.21 – Staff turnover

Details of the Trust’s staff turnover data can be found on the NHS Digital website.

Return to Contents

2.4 – The Accountability Report (Disclosures required in the Annual Report)

2.4.1 – Compliance with the Code of Governance for NHS Provider Trusts

The Board has overall responsibility for the administration of sound corporate governance throughout the organisation. The Code of Governance for NHS Provider Trusts (the Code) was published by NHS England. The purpose of the Code is to assist the boards of NHS trusts and NHS foundation trusts with ensuring good governance and to bring together best practice from public and private sector corporate governance.

2.4.1.1 – Comply or explain

The Code is issued as best practice, but also contains a number of main principles, supporting principles and code provisions on a ‘comply or explain’ basis. The Leeds and York NHS Foundation Trust has applied the principles of the Code of Governance for NHS Provider Trusts on a ‘comply or explain’ basis. The Code of Governance for NHS Provider Trusts, most recently revised in October 2022, is based on the principles of the UK Corporate Governance Code.

A full review of compliance with the Code is submitted to the Audit Committee on an annual basis to support this statement. A copy of the full report to the Audit Committee is available on request from the Associate Director for Corporate Governance. The Trust carried out a detailed self-assessment against the requirements of the Code and submitted the assessment to the Audit Committee for approval and to support this statement that the Trust continues to comply with the principles of the Code with the exceptions as listed in the table below.

Table 2.4A – Areas of non-compliance or limited compliance with the provisions of the Code of Governance
Code provision Requirement Explanation
B.2.5 The chair should be independent on appointment when assessed against the criteria set out in provision 2.6 below. The roles of chair and chief executive must not be exercised by the same individual. A chief executive should not become chair of the same trust. The board should identify a deputy or vice chair who could be the senior independent director. The chair should not sit on the audit committee. The chair of the audit committee, ideally, should not be the deputy or vice chair or senior independent director.
  • The Chair of the Trust and the Chief Executive abide by the division of responsibilities document.
  • The roles of the Chair and Chief Executive are undertaken by two different individuals.
  • The Chair of the Trust has completed a declaration as to their independence and it has been agreed by the Board that they meet this criteria.
  • Whilst the Chair is required only to do this on appointment, we test this (as for all other NEDs) on an annual basis.
  • The independence of the Chair is reported to the Council of Governors
  • The Chair of the Trust has not previously been the Chief Executive of the Trust.
  • The Board has identified a deputy chair and a senior independent director.
  • The deputy chair role is carried out by a NED for a period of normally 2 years therefore the SID could also be the Deputy Chair at some point and whilst we would not normally appoint the Deputy Chair as the SID, there are no restrictions to exclude the Deputy Chair being the SID.
  • At the current time, the Chair of the Audit Committee is not the SID.
  • The Audit Committee is not attended by the Chair of the Trust on a regular basis; however, an invitation is extended for them to attend once a year.

Explain

In November 2024 the Chair of the Audit Committee was reappointed by the Council of Governors as the Deputy Chair for a period of two years. The Council considered and supported the following rationale for this:

  • There have been new appointments to the Board of Directors and longer standing non-executive directors have ended their time with the Trust.
  • Reappointing the Deputy Chair for a further two years will provide consistency at the current time and allow time for the Chair of the Trust to consider who may be proposed as the next Deputy Chair.
B.2.12 Non-executive directors have a prime role in appointing and removing executive directors. They should scrutinise and hold to account the performance of management and individual executive directors against agreed performance objectives. The chair should hold meetings with the non-executive directors without the executive directors present.
  • The Board has a Nominations Committee. This committee has a prime role in appointing executive directors, having regard for the needs of the organisation and will, where necessary, take a lead role in removing executive directors.
  • Non-executive directors make up the majority of panel members for executive director recruitment.
  • The non-executive directors will in particular provide supportive challenge on the performance of the executive directors in achieving the standards, targets and measures set.
  • The Chair holds a monthly meeting with the non-executive directors as a group without the executive directors present.
  • The Remuneration Committee will receive and consider information related to the CEO and executive director appraisals and performance against agreed objectives.

Explain

Non-executive directors have no executive powers or responsibility for holding individual managers to account. This is the responsibility of the executive directors.
B.2.14 When appointing a director, the board of directors should take into account other demands on their time. Prior to appointment, the individual should disclose their significant commitments with an indication of the time involved. They should not take on material additional external appointments without prior approval of the board of directors, with the reasons for permitting significant appointments explained in the annual report. Full-time executive directors should not take on more than one non-executive directorship of another trust or organisation of comparable size and complexity, and not the chairpersonship of such an organisation.
  • All executive directors are appointed on a full-time basis and the CEO is responsible for ensuring there is sufficient time and resources for them to carry out their role.
  • NEDs are each asked to declare, on appointment and annually thereafter, that they can commit sufficient time to the role.
  • All NEDs have declared they have sufficient time to commit to their duties.
  • The letter of appointment clearly sets out the time commitment.
  • The ability to commit the necessary time to the role is explored at interview.
  • At this time no executive director is currently a non-executive director in any other organisation.

Explain

Regarding non-executive directors, who generally have a portfolio career, it is not appropriate for the Board of Directors to have power of veto over any part of a NED’s career. All NEDs are required to confirm they have sufficient time to carry out the role they are appointed to within the Trust. This is kept under review via the appraisal process.
C.2.2 There may be one or two nominations committees. If there are two, one will be responsible for considering nominations for executive directors and the other for non-executive directors (including the chair). The nominations committee(s) should regularly review the structure, size and composition of the board of directors and recommend changes where appropriate. In particular, the nominations committee(s) should evaluate, at least annually, the balance of skills, knowledge, experience and diversity on the board of directors and, in the light of this evaluation, describe the role and capabilities required for appointment of both executive and non-executive directors, including the chair.
  • The Trust has two “nominations committees” – one for executive directors (the Nominations Committee) and one for non-executive directors (the Appointments and Remuneration Committee). It is the responsibility of the Nominations Committee to have an overall view of the skills and knowledge required on the Board as a whole and where these pertain to non-executive directors it will inform the governors’ Appointments and Remuneration Committee of the skills to be appointed to.
  • The Nominations Committee meets as a vacancy arises to look at the skills and experience required and consider the diversity of members of the Board. It then agrees the role descriptions for members of the Board of Directors (executive and non-executive) where appointments need to be made.
  • The Nominations Committee has responsibility for succession planning and will receive assurance on the deputy arrangements in place.
  • The Nominations Committee agrees the role / job description for both the executive and non-executive directors.
  • The role descriptions for non-executive directors are presented to the Appointments and Remuneration Committee so appointments can be made against these.

Explain

The Nominations Committee may not meet annually but always considers the balance of skills, knowledge, experience and diversity on the Board of Directors whenever there is a vacancy.
C.5.3 To function effectively, all directors need appropriate knowledge of the trust and access to its operations and staff. Directors and governors also need to be appropriately briefed on values and all policies and procedures adopted by the trust.
  • There is in place a comprehensive induction process to ensure that all directors have an understanding of the Trust, its operations and staff.
  • There is an appropriate and effective induction session in place, which all new governors are required to attend.
  • There is a schedule in place for governors and directors to visit services.
  • Board Strategic Development Days allow members of the Board to look at matters in greater depth and understand the issues, thereby informing the discussion at Board meetings.
  • The Code of Conduct (which must be signed by both directors and governors) contains information about our values.
  • Directors are aware of and have access to all policies and procedures within the Trust as needed to support them carrying out their role.

Explain

Governors are not responsible for operational matters; however, they will be briefed on any policy that is applicable to them in their role as governors and this is done through bespoke documentation for governors.
D.2.1 The board of directors should establish an audit committee of independent non-executive directors, with a minimum membership of three or two in the case of smaller trusts. The chair of the board of directors should not be a member and the vice chair or senior independent director should not chair the audit committee. The board of directors should satisfy itself that at least one member has recent and relevant financial experience. The committee as a whole should have competence relevant to the sector in which the trust operates.
  • The Board has established an Audit Committee which is made up of three non-executive directors.
  • The Audit Committee is not attended by the Chair of the Trust on a regular basis; however, an invitation is extended for them to attend once a year. The Chair of the Trust is in attendance at these meetings and is not a committee member.
  • The terms of reference for the Audit Committee are available on the website.
  • The Chair of the Audit Committee has recent financial experience.

Explain

The Chair of the Audit Committee is currently the Deputy Chair of the Trust. The Deputy Chair was reappointed by the Council of Governors in November 2024 to provide consistency at a time when there have been recently appointed non-executive directors on the Board of Directors.
D.2.5 Legislation requires an NHS trust to have a policy on its purchase of non-audit services from its external auditor. An NHS foundation trust’s audit committee should develop and implement a policy on the engagement of the external auditor to supply non-audit services. The council of governors is responsible for appointing external auditors.
  • The Council of Governors is required to approve the process for the appointment of the external auditors.
  • The Audit Committee oversees the procurement process supported by the Head of Procurement, Assistant Director of Finance, and the Chief Financial Officer.

Explain

While a stand-alone policy is not in place, the process for the appointment of the External Auditor is included in the Trust’s Standing Financial Instructions (SFIs) and the NHS England guidance in this respect is also followed.

The SFIs state:

  • The Audit Committee should recommend an external auditor to the Council of Governors who will appoint them.
  • The Audit Committee can also recommend external auditors are appointed to review any aspect of the Trust’s performance, again approved by the Council of Governors.
  • The Audit Committee would set the parameters for the tender for an external auditor.
  • It also says the Trust shall implement a procedure for considering and approving any additional services to be provided by the auditor.

The NHS England guidance places restrictions on the non-audit work that can be carried out by the external auditor and the value of any work that can be done.
E.2.7 The remuneration committee should have delegated responsibility for setting remuneration for all executive directors, including pension rights and any compensation payments. The committee should also recommend and monitor the level and structure of remuneration for senior management. The board should define senior management for this purpose and this should normally include the first layer of management below board level.
  • The Remuneration Committee sets the pay for executive directors both at the point of advertising for a vacancy and then periodically if asked.
  • The Remuneration Committee has agreed that the pension rights for executive directors will be determined by the NHS Pension Scheme.

Explain

The staff on the next level down are paid under the NHS Agenda for Change pay structure and are therefore not within the remit of the Remuneration Committee. However, the only time the salaries of staff on Agenda for Change would be taken into account by the Remuneration Committee would be to ensure there is sufficient differential between those on Very Senior Manager (VSM) and their direct reports.

2.4.2 – Disclosure statements to be made in the Annual Report

The Code contains a number of disclosure statements that the Board is required to include in the Annual Report. The disclosure statements contained in the Annual Report are based on the 2022 version of the Code of Governance, and the table below shows how the Board has complied with those disclosures that it is required to include in this Annual Report.

The table below also includes a small number of specific additional requirements as set out in the NHS Foundation Trust Annual Reporting Manual, which directly relate to, or enhance the annual reporting requirements as set out in the Code of Governance for NHS Provider Trusts.

Table 2.4B – How we have complied with the disclosures we are required to report on in the Annual Report

Code provision Requirement Section in Annual Report
A 2.1 The board of directors should assess the basis on which the trust ensures its effectiveness, efficiency and economy, as well as the quality of its healthcare delivery over the long term, and contribution to the objectives of the ICP and ICB, and place-based partnerships. The board of directors should ensure the trust actively addresses opportunities to work with other providers to tackle shared challenges through entering into partnership arrangements such as provider collaboratives. The trust should describe in its annual report how opportunities and risks to future sustainability have been considered and addressed, and how its governance is contributing to the delivery of its strategy. Section 2.7.6

Section 1.1.7.3
A 2.3 The board of directors should assess and monitor culture. Where it is not satisfied that policy, practices or behaviour throughout the business are aligned with the trust’s vision, values and strategy, it should seek assurance that management has taken corrective action. The annual report should explain the board’s activities and any action taken, and the trust’s approach to investing in, rewarding and promoting the wellbeing of its workforce. Section 2.3.3.3
A 2.8 The board of directors should describe in the annual report how the interests of stakeholders, including system and place-based partners, have been considered in their discussions and decision-making, and set out the key partnerships for collaboration with other providers into which the trust has entered. The board of directors should keep engagement mechanisms under review so that they remain effective. The board should set out how the organisation’s governance processes oversee its collaboration with other organisations and any associated risk management arrangements. Section 1.1.7.3

Section 2.7.4.7
B 2.6 The board of directors should identify in the annual report each non-executive director it considers to be independent. Circumstances which are likely to impair, or could appear to impair, a non-executive director’s independence include, but are not limited to, whether a director:

  • has been an employee of the trust within the last two years
  • has, or has had within the last two years, a material business relationship with the trust either directly or as a partner, shareholder, director or senior employee of a body that has such a relationship with the trust
  • has received or receives remuneration from the trust apart from a director’s fee, participates in the trust’s performance-related pay scheme or is a member of the trust’s pension scheme
  • has close family ties with any of the trust’s advisers, directors or senior employees
  • holds cross-directorships or has significant links with other directors through involvement with other companies or bodies
  • has served on the trust board for more than six years from the date of their first appointment
  • is an appointed representative of the trust’s university medical or dental school.

Where any of these or other relevant circumstances apply, and the board of directors nonetheless considers that the non-executive director is independent, it needs to be clearly explained why.

 Section 2.1.1
B 2.13 The annual report should give the number of times the board and its committees met, and individual director attendance. Section 3.4
B 2.17 The schedule of matters reserved for the Board of Directors should include a clear statement detailing the roles and responsibilities of the Council of Governors. For foundation trusts, this schedule should include a clear statement detailing the roles and responsibilities of the council of governors. This statement should also describe how any disagreements between the council of governors and the board of directors will be resolved. The annual report should include this schedule of matters or a summary statement of how the board of directors and the council of governors operate, including a summary of the types of decisions to be taken by the board, the council of governors, board committees and the types of decisions which are delegated to the executive management of the board of directors. Section 4.4

Section 3.1
C 2.5 If an external consultancy is engaged, it should be identified in the annual report alongside a statement about any other connection it has with the trust or individual directors. Section 2.3.18
C 2.8 The annual report should describe the process followed by the council of governors to appoint the chair and non-executive directors. The main role and responsibilities of the nominations committee should be set out in publicly available written terms of reference. Section 2.2.4.3

Section 2.2.4.4
C 4.2 The board of directors should include in the annual report a description of each director’s skills, expertise and experience. Section 3.3
C 4.7 All trusts are strongly encouraged to carry out externally facilitated developmental reviews of their leadership and governance using the Well-led framework every three to five years, according to their circumstances. The external reviewer should be identified in the annual report and a statement made about any connection it has with the trust or individual directors. Section 2.1.7
C 4.13 The annual report should describe the work of the nominations committee(s), including:

  • the process used in relation to appointments, its approach to succession planning and how both support the development of a diverse pipeline
  • how the board has been evaluated, the nature and extent of an external evaluator’s contact with the board of directors and individual directors, the outcomes and actions taken, and how these have or will influence board composition
  • the policy on diversity and inclusion including in relation to disability, its objectives and linkage to trust vision, how it has been implemented and progress on achieving the objectives
  • the ethnic diversity of the board and senior managers, with reference to indicator nine of the NHS Workforce Race Equality Standard and how far the board reflects the ethnic diversity of the trust’s workforce and communities served
  • the gender balance of senior management and their direct reports.
  

Section 2.2.4.4

Section 2.7.3.5

Section 2.2.3.4

Section 2.2.3.4

Section 2.3.12
C 5.15 Foundation trust governors should canvass the opinion of the trust’s members and the public, and for appointed governors the body they represent, on the NHS foundation trust’s forward plan, including its objectives, priorities and strategy, and their views should be communicated to the board of directors. The annual report should contain a statement as to how this requirement has been undertaken and satisfied. Section 1.1.4
D 2.4 The annual report should include:

  • the significant issues relating to the financial statements that the audit committee considered, and how these issues were addressed.
  • An explanation of how the audit committee (and/or auditor panel for an NHS trust) has assessed the independence and effectiveness of the external audit process and its approach to the appointment or reappointment of the external auditor; length of tenure of the current audit firm, when a tender was last conducted and advance notice of any retendering plans
  • where there is no internal audit function, an explanation for the absence, how internal assurance is achieved and how this affects the external audit and an explanation of how auditor independence and objectivity are safeguarded if the external auditor provides non-audit services.
 Section 3.6

Section 6.1
D 2.6 The directors should explain in the annual report their responsibility for preparing the annual report and accounts, and state that they consider the annual report and accounts, taken as a whole, is fair, balanced and understandable, and provides the information necessary for stakeholders to assess the trust’s performance, business model and strategy. Section 2.1
D 2.7 The board of directors should carry out a robust assessment of the trust’s emerging and principal risks. The relevant reporting manuals will prescribe associated disclosure requirements for the annual report. Section 2.7
D 2.8 The board of directors should monitor the trust’s risk management and internal control systems and, at least annually, review their effectiveness and report on that review in the annual report. The monitoring and review should cover all material controls, including financial, operational and compliance controls. The board should report on internal control through the annual governance statement in the annual report. Section 2.7
D 2.9 In the annual accounts, the board of directors should state whether it considered it appropriate to adopt the going concern basis of accounting when preparing them and identify any material uncertainties regarding going concern. Trusts should refer to the DHSC group accounting manual and NHS foundation trust annual reporting manual which explain that this assessment should be based on whether a trust anticipates it will continue to provide its services in the public sector. As a result, material uncertainties over going concern are expected to be rare. Section 1.1.8
E 2.3 Where a trust releases an executive director, eg to serve as a non-executive director elsewhere, the remuneration disclosures in the annual report should include a statement as to whether or not the director will retain such earnings. N/A
Appendix B, para 2.3 (not in Schedule A) The annual report should identify:

  • the members of the council of governors
  • the constituency or organisation that they represent, whether they were elected or appointed, and the duration of their appointments.
  • the nominated lead governor.
 Section 4.1
Appendix B, para 2.14 (not in Schedule A) The board of directors should ensure that the NHS foundation trust provides effective mechanisms for communication between governors and members from its constituencies. Contact procedures for members who wish to communicate with governors and/or directors should be clear and made available to members on the NHS foundation trust’s website and in the annual report. Section 5.5

Section 3.3
Appendix B, para 2.15 (not in Schedule A) The board of directors should state in the annual report the steps it has taken to ensure that the members of the board, and in particular the non-executive directors, develop an understanding of the views of governors and members about the NHS foundation trust, eg through attendance at meetings of the council of governors, direct face-to-face contact, surveys of members’ opinions and consultations. Section 4.5
Additional requirement of FT ARM resulting from legislation If, during the financial year, the Governors have exercised their power under paragraph 10C of schedule 7 of the NHS Act 2006, then information on this must be included in the annual report. As inserted by section 151 (6) of the Health and Social Care Act 2012)

This is required by paragraph 26(2)(aa) of schedule 7 to the NHS Act 2006, as amended by section 151 (8) of the Health and Social Care Act 2012.

In relation to “the Governors have exercised their power”, power to require one or more of the directors to attend a governors’ meeting for the purpose of obtaining information about the foundation trust’s performance of its functions or the directors’ performance of their duties (and deciding whether to propose a vote on the foundation trust’s or directors’ performance).

 This power has not been exercised during the course of the financial year.

2.4.3 – Disclosure as per Schedule 7 of Large and Medium Sized Companies and Groups Regulations 2008

This section sets out those disclosures required as per Schedule 7 of the Large and Medium Sized Companies and Groups Regulations 2008 and where these have been reported.

Table 2.4C – Disclosures and where they are reported in the Annual Report

Disclosure requirement Statutory reference Section in which reported
Any important events since the end of the financial year affecting the NHS foundation trust 7(1) (a) Schedule 7 There have been no significant events after the year end
An indication of likely future developments 7(1) (b) Schedule 7 Section 1.1.7.2
An indication of any significant activities in the field of research and development 7(1) (c) Schedule 7 See the Trust’s Quality Account
An indication of the existence of branches outside the UK 7(1) (d) Schedule 7 Not applicable, no disclosure required
Policies applied during the financial year for giving full and fair consideration to applications for employment made by disabled persons, having regard to their particular aptitudes and abilities 10(3) (a) Schedule 7 Section 2.3.2
Policies applied during the financial year for continuing the employment of, and for arranging appropriate training for, employees who have become disabled persons during the period 10(3) (b) Schedule 7 Section 2.3.2
Policies applied during the financial year for the training career development and promotion of disabled employees 10(3) (c) Schedule 7 Section 2.3.2
Actions taken in the financial year to provide employees systematically with information on matters of concern to them as employees 11(3) (a) Schedule 7 Section 2.3.4
Section 2.3.6
Actions taken in the financial year to consult employees or their representatives on a regular basis so that the views of employees can be taken into account in making decisions which are likely to affect their interests 11(3) (b) Schedule 7 Section 2.3.4
Actions taken in the financial year to encourage the involvement of employees in the NHS foundation trust’s performance 11(3) (c) Schedule 7 Section 2.3.4 and 2.3.6
Actions taken in the financial year to achieve a common awareness on the part of all employees of the financial and economic factors affecting the performance of the NHS foundation trust 11(3) (d) Schedule 7 Section 2.3.6
In relation to the use of financial instruments, an indication of the financial risk management objectives and policies of the NHS foundation trust and the exposure of the entity to price risk, credit risk, liquidity risk and cash-flow risk, unless such information is not material for the assessment of the assets, liabilities, financial position and results of the entity 6 Schedule 7 Section 1.2.2

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2.5 – The Accountability Report (NHS Oversight Framework)

2.5.1 – NHS Oversight Framework

NHS England’s System Oversight Framework provides the framework for overseeing providers and identifying potential support needs. The framework looks at five themes:

  • Quality of care, access and outcomes
  • Finance and use of resources
  • People
  • Preventing ill health and reducing inequalities
  • Leadership and capability.

Based on information from these themes, providers are segmented from 1 to 4, where ‘4’ reflects providers with serious and complex issues, and ‘1’ reflects providers who are consistently high performing across the five areas above. A foundation trust will only be in segments 3 or 4 where it has been found to be in breach or suspected breach of its licence.

2.5.2 – Segmentation

Segmentation enables NHS England to take an overview of the level and nature of support required across the provider sector, and to target its support capacity as effectively as possible. During 2024/25 the focus was on trusts that met the criteria for segments 3 and 4. The default position being segment 2.

NHS England has assessed Leeds and York NHS Foundation Trust as segment 2. For ICBs and trusts in segments 1 and 2, overall support needs will be formally reviewed on a quarterly basis by the relevant regional team (in the case of individual organisations this will happen in partnership with the integrated care board)

There are no enforcement actions placed upon the Trust by NHS England and no actions are being taken or proposed by the organisation. This segmentation information is the Trust’s position as of 5th March 2025.

Confirmation from the Chief Executive

As Chief Executive I confirm that the information in this Performance Report is accurate to the best of my knowledge and that I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum.
Signed:
Date: 19 June 2025
Dr Sara Munro
Chief Executive

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2.6 – The Accountability Report (Statement of Accounting Officer’s Responsibilities)

2.6.1 – Statement of the Chief Executive’s responsibilities as the accounting officer of Leeds and York Partnership NHS Foundation Trust

The NHS Act 2006 states that the chief executive is the accounting officer of the NHS foundation trust. The relevant responsibilities of the accounting officer, including their responsibility for the propriety and regularity of public finances for which they are answerable, and for the keeping of proper accounts, are set out in the NHS Foundation Trust Accounting Officer Memorandum issued by NHS England.

NHS England has given Accounts Directions which require Leeds and York Partnership NHS Foundation Trust to prepare for each financial year a statement of accounts in the form and on the basis required by those Directions. The accounts are prepared on an accruals basis and must give a true and fair view of the state of affairs of Leeds and York Partnership NHS Foundation Trust and of its income and expenditure, other items of comprehensive income and cash flows for the financial year.

In preparing the accounts and overseeing the use of public funds, the Accounting Officer is required to comply with the requirements of the Department of Health and Social Care’s Group Accounting Manual and in particular to:

  • observe the Accounts Direction issued by NHS England, including the relevant accounting and disclosure requirements, and apply suitable accounting policies on a consistent basis
  • make judgements and estimates on a reasonable basis
  • state whether applicable accounting standards as set out in the NHS Foundation Trust Annual Reporting Manual (and the Department of Health and Social Care Group Accounting Manual) have been followed, and disclose and explain any material departures in the financial statements
  • ensure that the use of public funds complies with the relevant legislation, delegated authorities and guidance
  • confirm that the annual report and accounts, taken as a whole, is fair, balanced and understandable and provides the information necessary for patients, regulators and stakeholders to assess the NHS foundation trust’s performance, business model and strategy and
  • prepare the financial statements on a going concern basis and disclose any material uncertainties over going concern.

The accounting officer is responsible for keeping proper accounting records which disclose with reasonable accuracy at any time the financial position of the NHS foundation trust and to enable them to ensure that the accounts comply with requirements outlined in the above mentioned Act. The Accounting Officer is also responsible for safeguarding the assets of the NHS foundation trust and hence for taking reasonable steps for the prevention and detection of fraud and other irregularities.

As far as I am aware, there is no relevant audit information of which the foundation trust’s auditors are unaware, and I have taken all the steps that I ought to have taken to make myself aware of any relevant audit information and to establish that the entity’s auditors are aware of that information.

To the best of my knowledge and belief, I have properly discharged the responsibilities set out in the NHS Foundation Trust Accounting Officer Memorandum.

Signed:
Date: 19 June 2025
Dr Sara Munro
Chief Executive

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2.7 – The Accountability Report (Annual Governance Statement)

This statement seeks to make assurances about the framework of internal controls put in place to identify and manage risk for the period 1 April 2024 to 31 March 2025.

2.7.1 – Scope of responsibility

As Accounting Officer, I have responsibility for maintaining a sound system of internal control that supports the achievement of the NHS foundation trust’s policies, aims and objectives, whilst safeguarding the public funds and departmental assets for which I am personally responsible, in accordance with the responsibilities assigned to me. I am also responsible for ensuring that the NHS foundation trust is administered prudently and economically and that resources are applied efficiently and effectively. I also acknowledge my responsibilities as set out in the NHS Foundation Trust Accounting Officer Memorandum.

2.7.2 – The purpose of the system of internal control

The system of internal control is designed to manage risk to a reasonable level rather than to eliminate all risk of failure to achieve policies, aims and objectives; it can therefore only provide reasonable and not absolute assurance of effectiveness. The system of internal control is based on an ongoing process designed to identify and prioritise the risks to the achievement of the policies, aims and objectives of Leeds and York Partnership NHS Foundation Trust, to evaluate the likelihood of those risks being realised and the impact should they be realised, and to manage them efficiently, effectively and economically. The system of internal control has been in place in Leeds and York Partnership NHS Foundation Trust for the year ended 31 March 2025 and up to the date of approval of the annual report and accounts.

2.7.3 – Capacity to handle risk

The Board of Directors has overall responsibility for the governance of the Trust. It provides high-level leadership for risk management. The directors (both executive and non-executive) have appropriate skills and experience to carry out this function effectively and each member of the Board of Directors has corporate and joint responsibility for the management of risk across the organisation.

The Board is responsible for reviewing the effectiveness of the system of internal control, including systems and resources for managing all types of risk. The cycle of Board meetings continues to ensure that it devotes sufficient time to setting and monitoring strategy and having oversight of the key risks to achieving the strategic objectives. The Board also monitors performance against key targets and measures and considers any risks to achieving these.

A Board committee structure is in place and includes the: Quality Committee, Finance and Performance Committee, Mental Health Legislation Committee, Workforce Committee; and an Audit Committee. Each has delegated responsibility for monitoring risk within their areas of responsibility, including receiving the Board Assurance Framework in accordance with their terms of reference.

The Director of Nursing and Professions has overall lead responsibility for the development and implementation of a framework of organisational risk management, they also have responsibility for the management of risk of infection prevention and control and their portfolio incorporates the role of the Director for Infection Prevention and Control (DIPC). However, all executive directors have a duty to effectively manage risk within their own area of responsibility. The Chief Financial Officer (CFO) has delegated responsibility for managing the development and implementation of financial risk (including oversight for counter-fraud). Within their portfolio, the CFO also has the role of Senior Information Risk Officer (SIRO); and the Medical Director is the Caldicott Guardian and the Deputy Medical Director is the Responsible Officer. The responsibility for risk management is communicated to all staff through their job descriptions and a compulsory training module.

2.7.3.1 – Staff training

The Trust provides compulsory training for all staff to complete in order to comply with internal, legislative, and regulatory standards.  The composition of compulsory training programmes for different groups of staff have been risk assessed to ensure these are targeted, and that appropriate packages of training are in place.   We have a process for monitoring the uptake of compulsory training through a system called Learn.  The Director of People and Organisational Development oversees performance, and assurance reports are made to the Workforce Committee on performance against our target measures.

Risk management training and awareness is included in the compulsory health and safety training and is supported by local induction. The Trust’s risk management team delivers specific risk management training at all levels across the Trust.  The role of individual staff in managing risk is supported by a framework of policies and procedures that promotes learning from experiences and sharing good practice.

The Board also receives training on risk through bespoke training sessions which address their legal and statutory responsibilities as a Board member.

2.7.3.2 – Clinical governance

The Trust’s clinical governance structure is supported by a clinical governance framework, terms of reference and standardised agendas. The framework sets out the key activities related to clinical governance that are expected from all of the Trust’s services, to be undertaken and overseen to keep our organisation safe and effective.

The Trust’s clinical governance structure allows for the escalation and dissemination of information from ward level through to Board level via the Unified Clinical Governance Group and the Trustwide Clinical Governance Group.

2.7.3.3 – Patient Safety Incidents

The Trust actively encourages an open and honest culture of reporting incidents, risks and hazards.  It uses all such reports as an opportunity to learn and improve.   All reported incidents are reviewed by an assigned manager who reviews, completes and approves the incident. Any required additional support is offered to the relevant teams and any learning is identified including good practice.

The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety.   The PSIRF has replaced the Serious Incident Framework (2015).  The framework represents a significant shift in the way the NHS responds to patient safety incidents and is a major step towards establishing a safety management system across the NHS.

The PSIRF supports the development and maintenance of an effective patient safety incident response system that integrates four key aims:

  • Compassionate engagement and involvement of those affected by patient safety incidents
  • Application of a range of system-based approaches to learning from patient safety incidents
  • Considered and proportionate responses to patient safety incidents
  • Supportive oversight focused on strengthening response system functioning and improvement

The Trust’s PSIRF Policy was ratified on 25 June 2024. The PSIRF Policy and Plan are available on the Trust’s intranet.  On the 16 July 2024, the Trust held a PSIRF Launch Day event, where more than 80 members of staff from across various service lines attended.

Since the launch of PSIRF in June 2024, the Trust has completed the transition phase to the new framework, moving now to the embedding phase. This phase is expected to be completed by the end of the 2025. A cultural shift is required at all levels to best support the transition to and embedding of PSIRF across the Trust.

The Trust’s Learning from Healthcare Deaths Policy provides guidance on which deaths are in scope for an investigation or review in line with guidance from the Royal College of Psychiatrists. For deaths not listed as needing a Structured Judgement Review, the principles of PSIRF are applied and a learning response determined primarily by the incident being in scope for LYPFT and secondly by the potential for learning and improvement. This avoids delays in awaiting confirmation of the cause of death from the coroner before reaching a decision to complete a learning review.

The Learning from Incidents and Mortality Meeting (LIMM), Quality Assurance Group (QAG) and Trust Incident Review Group (TIRG) continue to operate to identify, allocate, review, and finally approve learning responses before they are shared with clinical services, families, and Coroners.

The frequency of LIMM meetings has changed from biweekly, to weekly. This change was required to increase the frequency of decision making around timely responses to patient safety events under the PSIRF framework.

The Trust also seeks additional learning opportunities through the identification and sharing of good practice, both internal and external to the Trust, including benchmarking; clinical supervision; reflective practice; individual and peer reviews; continuing professional development programmes; clinical audit; the application of evidence-based practice; and the application of robust health and safety processes.  Points of learning from any of these sources and potential changes in clinical practice are reviewed as necessary by the Trustwide Clinical Governance Group with assurances being made to the Board through the Quality Committee.

2.7.3.4 – NHS Resolution

The Trust is committed to the effective and timely investigation of any claims and subsequent response to any claim.  The Trust is a member of NHS Resolution (previously NHS Litigation Authority), a claims management scheme.  As a member, it respects the requirements and notes the recommendations of the Department of Health and Social Care and of NHS Resolution and its claim handling schemes.  The components of the scheme are set out below:

  • Clinical negligence claims against the Trust are covered by NHS Resolution’s Clinical Negligence Scheme for Trusts (CNST). The Trust is the legal defendant, however, the NHSR takes over full responsibility for handling the claim and meeting the associated costs.
  • Employer liability claims are covered by NHS Resolution’s Risk Pooling Scheme for Trusts (RPST) and Liability to Third Parties Scheme (LTPS). LTPS covers employers’ liability claims, from straightforward slips and trips in the workplace to serious manual handling, bullying and stress claims. In addition, LTPS covers public and products liability claims, from personal injury sustained by visitors to NHS premises to claims arising from breaches of the Human Rights Act, the Data Protection Act and the Defective Premises Act
  • Claims in respect of loss or damage to Trust property are covered by NHS Resolution’s Risk Pooling Scheme for Trusts (RPST) and the Property Expenses Scheme (PES). PES covers “first party” losses for material damage to buildings and contents from a variety of causes, including fire, theft and water damage. PES also offers business interruption expense cover arising from property damage.

2.7.3.5 – Work performed to assess Well-led

The Board is required to carry out an independent review of governance against the well-led framework every three years.  In 2024/25 the Trust commissioned TheValueCircle to undertake a Developmental Well-Led Review to assess governance, leadership, and strategic priorities. The review was conducted from September to November 2024 and applied the updated Care Quality Commission (CQC) framework to provide a comprehensive evaluation of the Trust’s capabilities, culture, and improvement opportunities.

The report provided a detailed analysis of both the structural elements of the organisation, whilst creating equal weighting and importance to behaviours and values. The independent review included:

  • an overall diagnostic of the organisation’s current governance arrangements, including a documentation review, using the CQC Well-Led Key Lines of Enquiry as a framework
  • interviews with each member of the Board, key members of the senior leadership team, staff representatives (including the Freedom to Speak Up Guardian) and identified external stakeholders
  • Focus groups with a cross-section of staff in each group
  • Observations of key governance and assurance forums, including Trust Board, council of governors, and Board committees
  • An analysis of the leadership behaviours and values as well as the governance systems, and processes.

The detailed outcome of the review was presented to the Board of Directors in January 2025 and concluded that the Trust is well-led, focuses on improving outcomes for the people it serves, and has a strong focus on co-production with staff, service users, and those with lived experience. The Board is a credible and capable team which is clearly sighted on the issues facing the Trust and the Board. The report identifies areas for improvement to further enhance Board capacity and capability alongside the existing Board development programme. The recommendations and any associated improvements will be monitored and implemented over the coming months.

2.7.4 – The risk control framework

The Trust has in place a comprehensive Risk Management Policy which is published on Staffnet and available to all staff. The purpose of this policy is to ensure the Trust manages risks in all areas using a systematic and consistent approach. It provides the framework for a robust risk management process throughout the Trust.  The document describes the Trust’s overall risk management process and the Trust’s risk identification, evaluation and control system.

All risks are assessed using an electronic system (DATIX) for recording and managing risk assessments, which can be accessed through Staffnet.  This system is used by staff to assess and record risk assessments, scoring risks using a 5 x 5 assessment of likelihood and impact.  Risks are then captured on the appropriate risk register which could be local, service line, corporate or strategic. We have in place an Executive Risk Management Group which is chaired by the Chief Executive.  This monitors risks, in particular those scoring 15 plus.

Local and service line level risks are discussed and reviewed within the appropriate operational or clinical governance meetings to ensure that appropriate and timely mitigation is in place. Where actions require escalation there should be a discussion within the operational or clinical governance meeting to identify the appropriate forum in which to raise issues and seek further support.   Clinical risk management is based on a structured clinical assessment model and supported by decision-making aids.

Risk is evaluated and controlled through the risk register; this is an evidence-based tool. The Trust’s risk register is held on DATIX and is a live and dynamic system.  Risks are developed and agreed by individual care services.  Strategic risks are signed off by senior managers within the clinical governance structure.

The Executive Risk Management Group (ERMG) is held on a bi-monthly basis and chaired by the Trust’s Chief Executive, the ERMG review specific risks rated 15 or above.  As part of the cycle of business there is a programme to ensure the review of risk registers for each service line.

The Patient Safety Team monitor the risk register to review outstanding risks and actions; this is communicated to the individual allocated to the risk on the 15th of each month.  Risks are reviewed and once evaluated as an accurate and controlled risk in the action plan, they will be signed off by a senior leader.

The Board Assurance Framework (BAF) is a vital document that tells the board, and the trust’s stakeholders, of strategic risks, which relate directly to achievement of the organisation’s strategy and are identified ‘top-down’ by the board or executive management. Operational risks, in contrast, arise from day-to-day activities and are usually identified ‘bottom-up’ by managers of individual services. Thus, the starting point for identifying the strategic risks should be the agreed strategic objectives.

2.7.4.1 – The Board Assurance Framework

The Board Assurance Framework (BAF) is one of the key risk assurance tools for the Board. It contains the principal risks to the achievement of the organisation’s strategic objectives, which are taken from the strategic risk register. It also sets out the Board’s risk appetite in relation to those risks.  The BAF enables the Board, primarily through its Board committee structure, to monitor the effectiveness of the controls required to minimise the principal risks to the achievement of the Trust’s objectives and therefore provides evidence to support this Annual Governance Statement.

In 2024/25 the strategic risks on the BAF were reviewed and agreed by the Board.  This was followed by a review of the controls, assurances and gaps to ensure these correctly reflected the refreshed risks.  In accordance with their Terms of Reference, the BAF is regularly reviewed by the Board and the Audit Committee.  The relevant sections of the BAF are also reviewed by the Board committees for those risks where they are named as assurance receivers.

2.7.4.2 – Regulation

Leeds and York Partnership NHS Foundation Trust is fully compliant with the registration requirements of the Care Quality Commission (CQC). Compliance with the CQC fundamental standards of quality and safety are one of the elements of the organisation’s risk management process.

Following a CQC inspection we will take a Trustwide view of the themes and have a holistic approach to resolving any issues and reducing the risk of non-conformity across the Trust. We ensure that the programme of activities and projects are working together and that benefits and improvements are brought to all core services.

In July 2024, CQC carried out an inspection of Children and Young People’s Inpatient Services, reviewing all quality statements under the five key questions (are services safe, effective, caring, responsive and well-led). The Trust is awaiting publication of the inspection report.

In September 2024, an inspection of Perinatal Services was undertaken. The CQC reviewed all quality statements under the five key questions. The inspection report was published in February 2025 with the services rated as ‘good’ overall receiving a rating of ‘good’ for safe, effective, caring and responsive and ‘requires improvement’ for well-led. Action is being taken to address the issues which led to the rating of ‘requires improvement’ for well-led.

The CQC Steering Group provides oversight and assurance in relation to CQC regulatory activity across the organisation. The group has responsibility for the delivery of the CQC Readiness Workplan which includes overseeing the peer review process, supporting Trustwide learning in relation to CQC activity, keeping abreast of any recent CQC activity, ensuring oversight of enquiries, reviewing and planning engagement meetings, ensuring oversight of actions from CQC inspections, ensuring oversight and assurance of peer review actions and the implementation of the new CQC inspection framework. The CQC Steering Group reports into the Trustwide Clinical Governance Group as a mechanism for providing assurance and for any escalations.

Quality and Safety Peer Reviews act as an internal assessment against regulatory compliance and standards. A standardised tool kit has been developed aligned to the CQC’s quality statements which are used to guide and direct their review of care services. Through the use of the standardised framework, areas for improvement, risks to service delivery and areas of good practice are identified. Experience from within the organisation is drawn upon to identify a team to effectively carry out the quality and safety review. Any must do or should do actions from the latest CQC inspection or Mental Health Act Inspection form part of the review and evidence is gathered to provide assurance that actions have been addressed and embedded.

Recommendations and actions are monitored through local governance systems to ensure progress and oversight. A system is in place to ensure that any recommendations and opportunities identified for learning, both at a service and organisational level, are shared through the governance structure. Any areas of concern are escalated through the Trustwide Clinical Governance Group.

2.7.4.3 – Governance, Accountability, Assurance and Performance Framework

The Trust has established a Governance, Accountability, Assurance and Performance Framework which sets out the organisation’s overarching principles and approach to delivering a quality service in a high performing organisation. The framework aims to ensure the Trust successfully delivers national standards for governance and performance through clear lines of accountability.

The framework describes how the Trust will use information management, alongside clear governance and accountability in order to deliver effective performance. This will be achieved through a tiered performance management process which demonstrates rigour, support, challenge, timely escalation and a consistent approach to clinical governance and performance management at all levels of the organisation.  It uses the approach set out in the System Oversight Framework from NHS England and the underpinning principles of the framework are aligned with the Trust’s strategy, values and behaviours and the CQC’s quality statements.

During quarter four of 2024/25, the Governance, Accountability, Assurance and Performance Framework was reviewed, amended where appropriate and agreed to remain the appropriate mechanism for managing governance. This will continue to be reviewed into 2025/26 to ensure it reflects the relevant governance structures through the coming year.

2.7.4.4 – Fraud, corruption and bribery

The Trust has policies and procedures in place that reduce the likelihood of fraud, corruption and bribery occurring. These include a Counter Fraud, Bribery and Corruption Policy, Standing Orders, Standing Financial Instructions, documented procedures, a system of internal control (including internal and external audit) and a system of risk assessment.  In addition, the Trust seeks to ensure that a comprehensive counter-fraud, corruption and bribery culture exists throughout the Trust via the appointment of a dedicated Local Counter-fraud Specialist (LCFS) in accordance with the standards set out in the provider contracts. The Trust has an annual risk-based counter fraud plan that is agreed with the LCFS, Chief Financial Officer and the Audit Committee.

Our LCFS has conducted work across all generic areas of counter-fraud activity, placing emphasis on the continued counter-fraud culture within our Trust and the prevention of fraud.  Counter Fraud induction material is provided to new members of staff and an ongoing programme of Counter Fraud Masterclasses are available for staff to attend throughout the year. The LCFS has continued to be proactive in their work and our staff have continued to be alerted to potential and real fraud risks.

2.7.4.5 – Principal risks to compliance with the NHS provider licence section 4 (governance)

The Trust has put in place measures to ensure the Board is able to confirm compliance with the NHS provider licence section 4 (governance) i.e. that we apply systems and standards of good corporate governance expected of a supplier of health services.

Our arrangements include a governance structure with four locally determined Board committees, over and above those required in statute (the Quality Committee, the Finance and Performance Committee, the Mental Health Legislation Committee and the Workforce Committee).  This ensures that members of the Board (particularly non-executive directors) are assured of the governance of the organisation and are assured on the quality of services (clinical and non-clinical).  There is also a comprehensive governance and management structure beneath the Executive Management Team to support executive directors in delivering their individual portfolios and support the Chief Executive in carrying out their duties as Accounting Officer.

The Board of Directors and its committees have agreed terms of reference setting out the accountabilities and the delegated authority they have been given by the Board to carry out work on its behalf.   The Trust has in place all the necessary statutory documentation including a constitution, a scheme of delegation and matters reserved to the Board.  All members of the Board have role descriptions, clearly setting out their duties and areas of accountability and there is a signed memorandum of understanding between the Chair and Chief Executive, setting out their respective responsibilities.  All Board members have been deemed to be Fit and Proper in accordance with the CQC standard.

In accordance with its cycle of business, the Board receives reports from executive directors that detail compliance with, and achievement of, regulatory, contractual and local targets.  The Board and its committees receive timely and accurate information at each of their meetings, and in accordance with their scheduled cycles of business.  Performance data relating to their areas of responsibility will be scrutinised.  Performance is also reported to the Council of Governors and governors are provided with an opportunity of holding the non-executive directors to account for the performance of the Board.

2.7.4.6 – Stakeholders and partners

The Trust involves stakeholders and partners in identifying and managing risks to its strategic objectives in a number of ways. These include:

  • working in partnership to develop system-wide plans with stakeholders across Leeds and West Yorkshire through the Integrated Care System (ICS) and Leeds Place-based Partnership processes
  • participating within the citywide strategic partnership group for mental health (West Yorkshire Mental Health Learning Disability and Autism Collaborative and its Committees in Common)
  • working with partners in health and social care services in developing and considering business and service change. The Trust has a framework for managing change to services agreed as part of its contracts with its main commissioners. The Trust also has good relationships with Overview and Scrutiny Committees
  • active relationships with Healthwatch and service user and carer groups, working with these groups on the management of service risks and change
  • active engagement with governors on strategic, service, and quality risks and changes including the setting of strategic priorities.

2.7.4.7 – NHS Pension Scheme control measures

As an employer with staff entitled to membership of the NHS Pension Scheme, control measures are in place to ensure all employer obligations contained within the scheme’s regulations are complied with. This includes ensuring that deductions from salary, employer’s contributions and payments to the scheme are in accordance with the scheme rules, and that member Pension Scheme records are accurately updated in accordance with the timescales detailed in the Regulations.

2.7.4.8 – Equality, diversity and human rights control measures

Control measures are in place to ensure that the organisation’s obligations under equality, diversity and human rights legislation are complied with. The Board has arrangements in place to ensure that the Trust complies with its legislative requirements. It has approved equality objectives, and an annual equality progress assessment is undertaken using the Equality Delivery System framework. These arrangements go beyond those required in statute, and provide a comprehensive system of support, understanding, participation and scrutiny in relation to equality and diversity; including a dedicated resourced Equality and Inclusion Team.

The Chair of the Trust ensures that the Board’s agendas adequately reflect the strategic discussions that need to take place at Board level in relation to equality, diversity and inclusion.

We have in place systems for monitoring equality progress and compliance against our People Plan 2024-2027 through our workforce governance structure including the Workforce Committee, which reports to the Board on performance against our target measures and the publication of our gender pay gap, workforce race and workforce disability standard data and annual actions.

Evidence that issues specific to equality and diversity have been considered is required before policy decisions are made. Equality analysis screening is required for all papers presented to governance meetings and for all new and revised procedural documents.

Alongside the arrangements we have in place for ensuring equity and diversity in the workforce, the Mental Health Legislation Committee receives reports on understanding why there are a disproportionate number of service users from ethnic minorities within our crisis service and detained under the Mental Health Act.  Assurance on the matters discussed at the committee meetings is provided to the Board through committee Chair reports with any matters of concern being escalated to the Board. These arrangements provide a robust level of support and co-ordination, including a dedicated senior Health Inequalities Lead.

The Trust also developed an Improving Health Equity Strategic Plan in 2024/25. Further details can be found in section 1.2.5.

2.7.4.9 – Carbon reduction delivery plans

The foundation trust has undertaken risk assessments on the effects of climate change and severe weather and has developed a Green Plan following the guidance of the Greener NHS programme. The trust ensures that its obligations under the Climate Change Act and the Adaptation Reporting requirements are complied with.

In 2021 all NHS Trusts were required to publish a Green Plan, outlining the Trust’s commitment to achieving Net Zero carbon emissions by 2045 in line with the NHS Strategy ‘Delivering a Net Zero NHS’. The Trust published ‘Our Green Plan’ and expanded the Sustainability Team, who developed a governance structure including an executive led steering group to deliver the Green Plan targets. In 2024/25 the Trust has planted native trees, developed an electric vehicle charging policy, implemented food waste collections, and is installing solar photovoltaic technology. The Green Plan has also been updated to cover 2025 – 2028, following guidance from Greener NHS, using existing Trust data, heat decarbonisation plans, and carbon footprinting. As part of the ongoing Green Plan project work, the Trust will undertake a climate change risk assessment and develop an adaptation plan using guidance recently released by Greener NHS.

2.7.4.10 – Workforce

The Trust’s People Plan has been refreshed and updated for 2024-2027. The Plan sets out our longer-term vision and ambitions as well as the annual priorities and deliverables.  We have piloted a new, more supportive approach to recruitment alongside values-based recruitment to support our aspirations to widen participation and adopt a more inclusive approach to recruitment. Plans are now in place to embed this new approach to recruitment across the Trust as appropriate.

Our workforce requirements and performance are managed through the workforce governance structure made up of a range of focused operational groups which identify short and long-term workforce requirements as well as solutions to meet immediate needs and long-term workforce planning which includes the development of new roles and career pathways.

The performance against workforce metrics is scrutinised by the Workforce Committee, the chair of which makes a report to the Board of Directors.

We recognise that many of our wider workforce challenges are best met by working in partnership. We work collaboratively within both Leeds and in the West Yorkshire Health and Care Partnership on shared leadership and development programmes, workforce planning and coaching and recruitment materials to promote working in the NHS. We are also active partners in the development and leadership of the West Yorkshire Mental Health Workforce Collaborative and the Leeds Anchor network.

The Trust has a comprehensive workforce plan that is updated annually and signed off by the Chief Executive. Progress against the plan is discussed by the Board along with local quality dashboard to provide assurance around safer staffing.

The introduction of new roles and any service redesigns are subject to a comprehensive quality impact assessment which is discussed at the appropriate governance meetings including the Efficiency and Productivity Programme, the Financial Planning Group and the People and Organisational Development Governance Group and can be escalated to the Workforce Committee if appropriate.

There is a formal escalation process in place for managing any business staffing issues and concerns via the Mental Health Optimal Staffing Tool (MHOST). In addition to, and to complement, Our People Plan, there are a number of specific professional strategies including the Medical Strategy, Nursing Strategy, and the Psychological Professions Strategy.  These strategies set out plans for the leadership and development of the workforce within the Trust for the next three years.

We also have a Wellbeing Guardian.  This role is fulfilled through the Chair of the Workforce Committee. On behalf of the Board, the Wellbeing Guardian holds the executives to account for matters relating to staff wellbeing. The Wellbeing Guardian aligns with nine principles outlined by NHS England.  Wellbeing is a standing agenda item at each of the Workforce Committee meetings.

2.7.4.11 – Non-executive Director Champions

In December 2021, NHS England released a guidance document titled ‘Enhancing board oversight: a new approach to NED champion roles’.  This recommended that the named individual should be the chair of the relevant Board committee with the requirements of the role being discharged through that committee. Below is how the Trust meets these requirements.

Table 2.7A – List of Non-executive Director Champions
NED champion role Legal basis NED / Board committee to oversee the NED Champion role How assurance will be received
Maternity board safety champion Recommended to all trusts providing maternity services. • Named champion to be the chair of the Quality Committee.
• Requirements of the role to be discharged through the Quality Committee.		 • Summary presentation of the Annual Quality Report from the Perinatal Service.
• Assurance and escalation from governance groups.
Health and wellbeing guardian Recommended to all trusts. • Named champion to be the chair of the Workforce Committee.
• Requirements of the role to be discharged through the Workforce Committee.		 • Wellbeing guardian report presented at every meeting.
• Escalations and assurance from governance groups.
• Data within the Workforce Performance Report.
Freedom to speak up Recommended to all trusts. • Named champion to be the Senior Independent Director.
• Requirements of the role to be discharged through the Board of Directors.		 • Freedom to Speak Up Guardian (FTSUG) update report.
• FTSUG Annual Report.
• Reports from the People and Organisational Development Governance Group to the Workforce Committee.
Doctors disciplinary Statutory for all trusts (advisory for foundation trusts). • Named champion to be the chair of the Workforce Committee.
• Requirements of the role to be discharged through the Workforce Committee.		 • Annual update on professional regulatory cases.
• Annual Employee Relations and Employment Liabilities Report.
Security management Statutory for all trusts, excluding foundation trusts. N/A – applicable to all trusts, excluding foundation trusts. N/A – applicable to all trusts, excluding foundation trusts.
Hip fracture, falls and dementia Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Annual Falls Report
• Data within the Combined Quality and Workforce Performance Report.
• Summary presentation of the Annual Quality Report from the Older Peoples Services.
• Escalations and assurance from governance groups.
Learning from deaths Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Six monthly Learning from Deaths Reports.
Safety and risk Recommended to all trusts. • Requirements of the role to be discharged through the Audit Committee. • Risk Management Annual Report.
• Board Assurance Framework.
Palliative and end of life care Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Six monthly Learning from Deaths Reports.
Health and safety Recommended to all trusts. • Requirements of the role to be discharged through the Audit Committee. • Health and Safety Annual Report.
• Health and safety updates to each meeting.
Children and young people Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Summary presentation of the Annual Quality Report from the CYPMHS.
• Escalations and assurance from governance groups.
Resuscitation Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Annual Report on Resuscitation
• Escalations and assurance from governance groups.
Cybersecurity Recommended to all trusts. • Requirements of the role to be discharged through the Finance and Performance Committee. • Quarterly Cyber Security Dashboard.
• Six-monthly updates on the Digital Plan.
Emergency preparedness Recommended to all trusts. • Requirements of the role to be discharged through the Finance and Performance Committee. • Emergency Preparedness, Resilience and Response Assurance Standard.
• Emergency Preparedness, Resilience and Response Annual Report.
Safeguarding Recommended to all trusts. • Requirements of the role to be discharged through the Quality Committee. • Safeguarding Annual Report.
• Assurance and escalations from Trustwide Safeguarding Group.
Counter fraud No longer a statutory requirement to designate a NED champion for counter fraud. N/A

The 2004 Counter Fraud Directions included a requirement for NHS trusts to designate a NED Champion for counter fraud. However, these were revoked by the 2017 Directions on Counter Fraud, so there is no longer a statutory requirement to designate a NED champion for counter fraud.

It should be noted that the Trust’s Local Counter Fraud Specialist attends and submits information to each Audit Committee meeting.

 N/A

The 2004 Counter Fraud Directions included a requirement for NHS trusts to designate a NED Champion for counter fraud. However, these were revoked by the 2017 Directions on Counter Fraud, so there is no longer a statutory requirement to designate a NED champion for counter fraud.

It should be noted that the Trust’s Local Counter Fraud Specialist attends and submits information to each Audit Committee meeting.
Procurement Recommended to all trusts. • Requirements of the role to be discharged through the Finance and Performance Committee. • Six-monthly updates on the Procurement Plan.
• Bi-annual North of England Commercial Procurement Collaborative update report.
Security management – violence and aggression Recommended to all trusts. • Requirements of the role to be discharged through the Workforce Committee. • Wellbeing guardian report presented at every meeting.
• Escalations and assurance from governance groups.
• Bi-annual report on health and safety.
• Bi-annual report on the Violence Prevention and Reduction Standard.
Patient experience N/A • Named champion to be Kaneez Khan • Attendance at the Patient Experience and Involvement Strategic Steering Group
Sustainability N/A • Named champion to be Katy Wilburn • Six-monthly updates on the Green Plan.
• Meetings with the Sustainability Team each quarter.

2.7.4.12 Registers of Interests

The Trust has published on its website an up-to-date register of interests, including gifts and hospitality, for decision-making staff (as defined by the Trust with reference to the guidance) within the past twelve months, as required by the ‘Managing Conflicts of Interest in the NHS’ guidance.

2.7.5 – Key risks for the organisation

Key risks for the organisation are those that have been identified as strategic risks, held on the strategic risk register.  These are also set out in our Board Assurance Framework (BAF).  Each of the strategic risks have an identified executive director and management lead.  They are managed through the risk management, risk register and operational planning processes.  They are reported to the Executive Risk Management Group, Board committees and the Board through the BAF.  Behind each risk is a detailed risk assessment which sets out the controls and mitigations.

During 2024/25 the Board considered and refreshed the strategic risks as per established processes, through Board discussions and workshops, and in consultation with the Board committees.  Following the agreement of the Trust’s strategic objectives and priorities for the coming year, a comprehensive review of the BAF will take place in quarter one of 2025/26 to ensure that it is reflective of the associated high-level risks aligned to the objectives.

In summary the risks are described as follows:

  • SR1 – If there is a breakdown of quality including safety assurance processes, we risk not being able to maintain standards of safe practice, meeting population health needs and compliance with regulatory requirements.
  • SR2 – There is a risk that we fail to make the improvements outlined in the Quality Strategic Plan and that this has an impact on how we understand and act on the care of those who use our services.
  • SR3 – There is a risk that we fail to deliver a culture and environment that recruits, retains, and attends to the wellbeing of staff to enable them to be their best and deliver quality services now and in the future.
  • SR4 – There is a risk that a lack of financial sustainability results in the destabilisation of the organisation and an inability to meet our objectives.
  • SR5 – Due to an inability to provide adequate working and care environments we risk being unable to deliver safe and effective services.
  • SR6 – As a result of insecure, inadequate and poorly utilised digital technologies there is a risk the quality and continuity of services is compromised.
  • SR7 – There is a risk we fail to understand, plan and deliver services that meet the health needs of the population we serve.

The Board and its committees continue to keep the risks under review at each of their meetings in order to gain assurances on the actions being taken.

2.7.6 – Review of economy, efficiency and effectiveness of the use of resources

We published our new five-year strategy titled ‘Improving the health and lives of the communities we serve: from 2025 to 2030’ in November 2024. This set out our ambitions and plans over five years.  Our strategy is relevant and fully aligned with those key themes within national and local strategies that are relevant to people using our services, carers, our staff, and our organisation as a whole.  At the time of writing our strategy, the government is developing a new 10-year strategy for health.  This will set out how it will achieve its three strategic shifts of:

  1. Hospital to community
  2. Treatment to prevention
  3. Analogue to digital

To enable the delivery of our strategy we have developed a set of strategic plans.  These are our delivery plans which provide detailed information about how we will achieve our ambitions and include our plans for: care services; estates; health informatics; people; and quality.  Each year we have set out our annual actions for achievement as part of our planning and priorities and in 2024/25 the Board agreed its main areas of focus were workforce, digital, quality, estates and clinical services.  It received refreshed plans setting out the priorities and has also received updates on progress.

The Trust produced a Financial Plan for 2024/25 that detailed the expected financial performance for the financial year. This plan was signed off by the Board of Directors prior to submission to NHS England. To be assured of progress against the plan (both financial and operational) the Board received regular updates through the Finance and Performance Committee.

The Financial Planning Group has been set up to provide routine assurance and oversight related to the quality and financial impact of existing efficiency schemes. This group meets on a monthly basis and is chaired by the Chief Financial Officer. The ongoing process of assessing the actual impact on quality and delivery is routinely undertaken by each responsible directorate management team meetings and escalated through to the Financial Planning Group. All accepted efficiency plans are presented to both the Quality Committee and Finance and Performance Committee where assurance is provided on the rigour of the quality and delivery impact assessment process.

The Trust operates within a well-defined corporate governance framework, with financial governance being set out through a number of documents including the Corporate Governance Policy, Standing Financial Instructions, financial procedures, and the Scheme of Delegation and Matters Reserved to the Board of Directors. This framework includes explicit arrangements for:

  • setting and monitoring financial budgets
  • delegation of authority for committing resources
  • performance management
  • achieving value for money.

The Trust receives its core accounting systems and processes from third parties. The main accounting functions are provided by NHS Shared Business Services Ltd. Assurance is provided to the Trust through the Statement of Auditing Standards (SAS) No. 70, prepared by NHS Shared Business Services independent auditors. This internationally recognised auditing standard signifies that a service organisation has had its control objectives and control activities examined by an independent accounting and auditing firm.

The payroll service is provided by the Leeds Teaching Hospitals NHS Trust (LTHT). Assurance is received from LTHT and its internal auditors regarding both the performance and controls associated with the Electronic Staff Record (ESR) system, which concludes that the payroll function is operational within an environment of effective control. The last internal audit report covered 2022/23 and was issued in May 2023. The next audit will take place in 2025/26.

The structures that have been applied in maintaining and reviewing economy, efficiency and effective use of resources include:

  • The Board of Directors which receives reports on any significant events or matters that affect the Trust.  The Board also receives a Chief Operating Officers’ Report at each meeting which reports on performance against the Trust’s regulatory, contractual and internal targets and standards; financial reports from the Chief Financial Officer; the Board Assurance Framework; and reports from the Chairs of its committees including the Audit Committee.
  • Internal Audit (NHS Audit Yorkshire) provides an independent and objective opinion on the degree to which risk management, controls and governance support the achievement of the Trust’s objectives.  The audit plan is derived from an assessment of risk areas within the Trust and includes all areas where Internal Audit is named in the Board Assurance Framework as a provider of assurance on the effectiveness of key controls.

In 2024/25 the Internal Audit reports issued in the year have generated an overall opinion of significant assurance as detailed in the Head of Internal Audit Opinion. It should also be noted that within 2024/25 there were three reports issued with a ‘limited assurance’ opinion, two reports issued with a ‘low assurance’ opinion and one report issued with a split significant/limited opinion:

  • LY02/2025 Mental Capacity Act (limited) – the objective of this review was to gain assurance that the Trust is compliant with the Mental Capacity Act (2005).
  • LY04/2025 Appraisals: Performance Delivery Reviews (limited) – the objective of this review was to gain assurance that the Trust is compliant with the appraisal process.
  • LY06/2025 Clinical Supervision (limited) – the objective of this review was to gain assurance that there are effective clinical supervision systems and process in place to facilitate safe and effective care.
  • LY08/2025 Policy for the Payment & Reimbursement of Service Users, Patients, Carers and Members of the Public (low) – the objective of this review was to provide assurance on the implementation and effectiveness of the Policy for the Payment & Reimbursement of Service Users, Patients, Carers and Members of the Public.
  • LY11/2025 Service Users Monies (low) – the objective of this review was to gain assurance that the Trust is effectively safeguarding service user’s monies, with a focus on procedures for the management of monies for tenants in the Specialised Supported Living Service (SSLS).
  • LY12/2025 Integrated Governance and Risk Management Framework (split significant/limited opinion – the limited portion of the opinion related to the Risk Management Framework) – the objective of this review was to provide assurance on the risk management and integrated governance systems in place within the Trust designed to provide effective escalation and assurance between the Board and Committees.
  • External Audit (KPMG) provides audit scrutiny of the annual financial statements, and looks at the Trust’s economy, efficiency and effectiveness in its use of resources.  External audit also provides assurance through the review of systems and processes as part of the annual audit plan.

The audit team will carry out the audit of the 2024/25 annual accounts and will provide a report on their findings (ISA 260 Report) to the Audit Committee which is the body ‘charged with governance’ in the Trust.

  • The Audit Committee is a committee of the Board of Directors, the membership of which is made up of non-executive directors. It reports directly to the Board.  The committee has responsibility for being assured in respect of the Trust’s systems of internal control, including risk management, and for overseeing the activities of internal audit, external audit and the local counter-fraud services.

The committee executes this role by approving the annual plans for internal and external audit and counter-fraud; receiving reports and updates against those plans; reviewing risks through the Board Assurance Framework; carrying out deep-dives into any area where further assurance is required on an area of risk

  • The Board committee structure is made up of four locally determined committees; the Quality Committee, the Mental Health Legislation Committee, Workforce Committee and the Finance and Performance Committee; each of which has responsibility for assurance in areas of clinical and financial performance and compliance. The Board also has two further statutory committees: the Nominations Committee and the Remuneration Committee.  Each of the Board committees is chaired by a non-executive director, with the Remuneration Committee being made up wholly of non-executive directors.

2.7.7 – Information governance

2.7.7.1   Incidents Relating to Information Governance

The Trust has an obligation to assess data protection & cyber security incidents against the NHS Digital methodology and report serious incidents to the Information Commissioner’s Office (ICO) and, for the most serious or large-scale incidents, to the Department of Health & Social Care (DHSC). Aligned to the Data Protection Act (2018) & UK-GDPR, the NHS Digital incident grading methodology employs a 5 x 5 likelihood versus impact approach, assessing both the likelihood and severity of harm caused.

Since May 2018, incidents are graded as follows:

  • Non-Reportable
  • ICO Reportable
  • ICO Reportable and DHSC Notified

Below is an analysis of our information governance incident reporting records for 2024/25.  This shows that four incidents met the reporting threshold in the financial year.

Table 2.7B – Summary of Reportable Incidents involving personal data as reported to the ICO / DHSC in 2024/25
Date of incident (month) Nature of incident Nature of data involved Number of people potentially affected Notification steps
06/2024 Inappropriate and unlawful access to patient data Patient data stored within the Trust EPR system 1 Reported via national data breach reporting tool – ICO notified.
No further action by ICO.
08/2024 3rd party supplier sub-contractor data breach Bank staff contact details, shifts times and places 888 Reported via national data breach reporting tool– ICO & DHSC notified.
No further action by ICO.
03/2025 Inappropriate and unlawful access to patient data Patient data stored within the Trust EPR system 1 Reported via national data breach reporting tool – ICO notified.
ICO outcome awaited
03/2025 Inappropriate and unlawful access to patient data Patient data stored within the Trust EPR system 1 Reported via national data breach reporting tool – ICO notified.
ICO outcome awaited

Further action taken:

In all cases above, the Head of Information Governance has provided subject matter expert input to the management, investigatory & HR processes for the staff concerned. Duty of Candour to notify affected data subjects has been undertaken.

We will continue to monitor and assess information governance / data protection / cyber security incidents. When weaknesses in systems or processes are identified, interventions will be undertaken. Low-level and near-miss events will be monitored and when there are common themes we will undertake Trust-wide communications to address these themes. A 6-monthly report is made to our Trustwide Clinical Governance Group, highlighting themes, trends, or ‘hot spot’ teams emerging through our analysis of incident reporting so that lessons can be learned & cascaded through service management structures. We will continue to support information governance training via the national e-learning tool. All staff undertake annual refresher training as a reminder of their information governance obligations and to raise cyber-security awareness.

The Trust has a robust Information Governance function and framework that utilises subject matter expertise from Information Governance (IG), Information, Communication and Technology (ICT), Networks, Informatics, Health Records and Systems Administration. The Trust’s Senior Information Risk Owner (Chief Financial Officer) and Caldicott Guardian (Medical Director) are members of the Information Governance Group. The Group makes quarterly assurance reports to the Finance and Performance Committee, thereby maintaining a reporting line to the Board as required by regulation. It maintains effective links with the Trust’s clinical teams by the escalation of incidents to the Trustwide Clinical Governance Group on a six-monthly basis, and through direct contact with staff reporting incidents to give direction on incident management and Duty of Candour actions.

2.7.7.2   Data security

The Trust follows guidance for compliance, standards and frameworks with national and international bodies such as NHS England, ISO, CAF, NIST and best practice recommendations from security partners. Penetration Testing and vulnerability assessments are conducted regularly as mandated by the NHS Data Security & Protection (DSP) Toolkit. The Trust is also enhancing resources and technologies for Cyber Security across a wide spectrum.

The Trust recognises that our approach to information security requires both a technical and organisational approach as described in the Data Protection Principle (f).

The Trust has a highly developed and mature approach to information governance, which includes high compliance with staff IG training and a comprehensive suite of IG-related procedural documents, giving instruction and regulation to our staff. The Trust deploys the mandatory public sector safeguards recommended by the HM Government Cabinet Office “Data Handling Procedures in Government”, including the operation of secure network storage, port control and the provision of encrypted digital media, and the encryption of high-risk portable computing resources.

The Trust continues to use NHSmail, facilitating secure digital communications with other NHS partners and the wider public sector and to local partner organisations operating email services with Transport Level Security. NHSmail [SECURE] also gives us secure communication channels to otherwise unsecured email endpoints.

Senior managers in ICT receive the NHS England National CSOC Weekly Cyber Alert Bulletin broadcasts and ad-hoc high-risk reports, to maintain an awareness of current information security threats so that timely and appropriate action can be taken where necessary. We have embedded the use of a Cyber Alert Bulletin action tracking solution, with all Cyber Alert Bulletin threats recorded, assessed for exposure and potential impact, with solutions tracked, implemented and reported monthly to the IG Group and Digital Steering Group.

The Trust continues to use the national NHS IG Training offering, Data Security Awareness Level 1, which contains regularly refreshed content on IG in a healthcare context and the user behaviour aspects of information / cyber security.

We have a robust approach to business continuity (BC) / disaster recovery (DR) within ICT, with senior management taking ownership of developing BC/DR plans for their services. Work is continuing to align ICT BC/DR with clinical service system criticality. Our plans are tested using National Cyber Security Centre table-top exercises, with themes chosen as highly relevant to the current threat landscape. The Trust’s Emergency Planning & Resilience Team also lead annual day-long exercises with multi-disciplinary Trustwide representative participation, the aim being to test & embed BC/DR planning & readiness collaboratively across care, ICT and other support services.

The Trust submitted a self-assessment against the NHS England Data Security and Protection Toolkit of ‘Standards Met’ on 21 June 2024, which was supported by the findings of the usual Internal Audit review, appraising a sample of 13 of the compulsory Assertions, in alignment with the national DSP Toolkit ‘Strengthening Assurance Audit Framework’, with an outcome of ‘Substantial Assurance’ achieved at audit, and notably with no areas for improvement identified – a very pleasing outcome.

The Trust is currently working towards the submission of the new Cyber Assessment Framework (CAF)-aligned 2024/25 Toolkit, to be finalised with an end date of 30 June 2025, and we will once again undertake a round of Internal Audit scrutiny.

2.7.8 – Data quality and governance

The following steps have been put in place to assure the Board that the Quality Account presents a balanced view and that there are appropriate arrangements in place to ensure the quality and accuracy of performance information:

  • performance reports to the Board of Directors, which set out performance against external requirements including NHS England targets, the System Oversight Framework and our contractual requirements with our commissioners
  • assurance regarding maintaining CQC registration requirements is managed by the Director of Nursing and Professions with assurances being made to the Quality Committee
  • performance reports to the Council of Governors
  • the Executive Performance Overview Group seeks to understand challenges within the service lines.

There are systems and processes in place for the collection, recording, analysis and reporting of data which will ensure this is accurate, valid, reliable, timely, relevant, and complete.

To manage the risk of there being incorrect data, the Trust has a Data Quality Policy (which was refreshed in March 2024) which clearly identifies roles and responsibilities for the collection and input of service user information into patient records’ systems. The Digital, Data and Technology Team deals with erroneous entries and there are systems and processes in place to alert relevant managers of any issues to ensure that data presented in the Quality Account is both accurate and reliable. Data quality reports are available so that data quality issues are dealt with proactively and quickly to maintain data integrity.

2.7.9 – Review of effectiveness

As Accounting Officer, I have responsibility for reviewing the effectiveness of the system of internal control. My review of the effectiveness of the system of internal control is informed by the work of the internal auditors, clinical audit, and the executive managers and clinical leads within Leeds and York Partnership NHS Foundation Trust who have responsibility for the development and maintenance of the internal control framework. I have drawn on performance information available to me. My review is also informed by comments made by the external auditors in their management letter and other reports. I have been advised on the implications of the result of my review of the effectiveness of the system of internal control by the Board, the Audit Committee, the Quality Committee, the Finance and Performance Committee, the Workforce Committee and the Mental Health Legislation Committee, and a plan to address weaknesses and ensure continuous improvement of the system is in place.

2.7.10 – Conclusion

In summary, the Trust has a sound system of internal control in place. The systems of internal control are designed to ensure delivery of the Trust’s goals and strategic objectives and to manage and minimise exposure to risks and no significant internal control issues have been identified.

I am satisfied that the process for identifying and managing risks is robust and dynamic as evidenced above. I am also satisfied that the Trust is doing all it can to mitigate the risks that have been identified and has in place a sufficient system of internal control to manage the strategic and other organisational risks.

Signed:
Date: 19 June 2025
Dr Sara Munro
Chief Executive

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3 – The Board of Directors (further information)

3.1 – Introduction

The Board of Directors is the body legally responsible for the day-to-day management of the organisation and is accountable for the operational delivery of services, targets and performance, as well as the definition and implementation of our strategy.  It has a duty to ensure the provision of safe and effective services for our service users.  It does this by having in place effective governance structures and by:

  • Establishing and upholding our values and culture
  • Setting the strategic direction
  • Ensuring we provide high quality, safe, effective and service user focused services
  • Promoting effective dialogue with our local communities and partners
  • Monitoring performance against our objectives, targets, measures and standards
  • Providing effective financial stewardship
  • Ensuring high standards of governance are applied across the organisation.

The Chair of the Trust is responsible for ensuring that the Board of Directors focuses on the strategic development of our organisation and that robust governance and accountability arrangements are in place.  The Chair of the Trust chairs both the Board of Directors and the Council of Governors and ensures there is effective communication between the two bodies and that, where necessary, the views of the governors are taken into account by the Board.

Whilst the executive directors individually are accountable to the Chief Executive for the day-to-day operational management of the organisation, they, along with the non-executive directors, are part of the unitary Board.  They all share corporate responsibility and liability for ensuring that our Trust operates safely, effectively and economically. They do this by making objective decisions in the best interests of the Trust.  The non-executive directors will assure themselves of performance by holding the executive directors to account for the achievement of the agreed goals, objectives, targets and measures.

The Board sets out the Trust’s vision, values and standards of conduct, whilst ensuring that its obligations to our members and the public are understood, clearly communicated and met.  This is achieved by ensuring that the Board is made up of individuals who have the appropriate balance of skills, experience, independence and knowledge to enable the Board to discharge its duties and responsibilities effectively. The Board provides entrepreneurial leadership in a transparent manner and supports Trust staff in accordance with the Trust’s values and accepted standards of behaviour in public life, including the Nolan Principles of:

  • Selflessness
  • Integrity
  • Objectivity
  • Accountability
  • Openness
  • Honesty
  • Leadership.

The Board will reserve certain matters to itself and will delegate others to specific committees and executive directors. Details of this are set out in a document called Reservation of Powers to the Board of Directors and Council of Governors and Schedule of Decisions/Duties Delegated by the Board of Directors.

For more information visit our Board of Directors page.

3.2 – Composition of the Board of Directors

3.2.1 – Non-executive directors

Our non-executive director (NED) team is made up of seven NEDs including a non-executive Chair. NEDs provide constructive challenge and strategic guidance and lead in holding the executive directors to account. They scrutinise the performance of the executive directors in meeting agreed goals and objectives, receive information, and monitor the reporting of performance. They seek assurance on the integrity of clinical and other information, and make sure that clinical quality controls and systems of risk management and governance are robust and implemented.

More detailed information about our non-executive directors is set out in the Remuneration Report in Part A section 2.2 of this Annual Report.

3.2.2 – Executive directors

The executive director team is made up of six executive directors, including the Chief Executive. The team is made up as follows:

  • Chief Executive
  • Medical Director
  • Chief Financial Officer and Deputy Chief Executive
  • Director of Nursing and Professions
  • Chief Operating Officer
  • Director of People and Organisational Development

More detailed information about our executive directors is set out in the Remuneration Report in Part A section 2.2 of this Annual Report.

3.2.3 – Members of the Board of Directors

Information about who our members of our Board of Directors were on 31 March 2025 can be found in Part A section 2.1.1 of this Annual Report.

3.3 – Profile of members of the Board of Directors

Merran McRae, Chair of the Trust

Merran is the Chair of the Trust Board.  As Chair, along with the non-executive directors, her role is to hold the Chief Executive and her executive team to account for the delivery of the organisation’s strategic aims and objectives.  Merran chairs the Board of Directors, the Council of Governors, the Remuneration Committee, the Nominations Committee and the governors’ Appointments and Remuneration Committee.

Merran has over 30 years of experience in Local Government, leading services across housing, social care, culture and community development. Previously, she has been a statutory Director of Adult Social Care, Chief Executive at both Calderdale and Wakefield Councils and a Trustee of the Hollybank Trust, which provides services for children and adults with profound and multiple disabilities. She has a professional qualification in housing, an MBA and is also a qualified executive coach. Merran is a Trustee of The Yorkshire Sculpture Park and a Deputy Lieutenant with the West Yorkshire Lieutenancy.

Zoe Burns-Shore, Non-executive Director (Chair of the Workforce Committee)

Zoe’s role on the Board is to hold the Chief Executive and her executive team to account for the delivery of the organisation’s strategic aims and objectives.  She is the Chair of the Workforce Committee and a member of the Quality Committee.

By holding the executive directors to account, Zoe is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way. She is also able to be assured that clinical quality controls and systems of risk management and governance are robust and implemented. She contributes to improving the experience of staff, service users and carers by having a particular focus on workforce related matters including being the named Wellbeing Guardian and Doctors Disciplinary Champion.

Zoe has over 20 years of experience leading teams across many different sectors, both public and private. She specialises in developing customer and employee experience strategies that work together to create better outcomes. Zoe is passionate about organisational culture and creating environments that are diverse and inclusive, allowing people to thrive.

Dr Frances Healey, Non-executive Director (Chair of the Quality Committee)

Frances’ role on the Board is to provide constructive challenge, strategic guidance, and specialist advice, including holding the Chief Executive and her executive team to account for the delivery of the organisation’s agreed goals and objectives.  By holding the executive directors to account she is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way.  She is also able to be assured that clinical quality controls, and systems of risk management and governance, are robust and implemented.

Frances is a member of the Audit Committee and is the named Maternity Board Safety Champion. She is the Chair of the Quality Committee, which has responsibility for providing assurance to the Board of Directors on the effectiveness of the Trust’s quality systems and processes, the quality of the services provided by the Trust, and the control and management of quality related risks within the Trust.

Frances is a registered general nurse and mental health nurse with over 40 years of clinical, research, leadership, patient safety and quality improvement experience in national, regional, and NHS trust roles. Frances is a Visiting Professor at the University of Leeds and a Trustee of the National Confidential Enquiry into Patient Outcomes and Death (NCEPOD).

Cleveland Henry, Non-executive Director (Chair of the Finance and Performance Committee and Senior Independent Director)

Cleveland’s role as a non-executive director is to hold the Chief Executive and the executive team to account for the delivery of the organisation’s strategic aims and objectives. By holding the executive directors to account he is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way.  He is also able to be assured that clinical quality controls, and systems of risk management and governance, are robust and implemented.

Cleveland is the Chair of the Finance and Performance Committee and a member of the Audit Committee. As Chair of the Finance and Performance Committee, Cleveland makes sure that we are in a strong position to use the money we receive in the best way we can to benefit our service users and their carers, and that we take opportunities to build a sustainable organisation able to continue to provide high quality services.

He has also been appointed by the Board as the Senior Independent Director.  This role means that he is available to members of the Trust and to governors in instances where they have concerns which have been raised through the usual channels of Chair, Chief Executive, Chief Financial Officer or Trust Board Secretary and these have failed to resolve the issue.  He is also available where it would be inappropriate to use such channels. Cleveland is also the named Freedom to Speak Up Champion.

Cleveland has over 30 years of delivery experience in several industries, with a primary expertise in technology.  He currently holds a substantial role as a Delivery Director for a Health Technology organisation. Prior to this, Cleveland was a Senior Director for the Health division of a Cloud Technology organisation and previous to that he was Programme Director at NHS Digital. Cleveland is also the Chair of the Board of Trustees for the Leeds Community Foundation.

Kaneez Khan MBE, Non-executive Director (Chair of the Mental Health Legislation Committee)

Kaneez’s role on the Board is to hold the Chief Executive and her executive team to account for the delivery of the organisation’s strategic aims and objectives.  She is the Chair of the Mental Health Legislation Committee, a member of the Workforce Committee and the NED champion for patient experience.

By holding the executive directors to account Kaneez is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way. She is also able to be assured that clinical quality controls, and systems of risk management and governance, are robust and implemented. As Chair of the Mental Health Legislation Committee, Kaneez seeks assurance that we are appropriately administering the legislation relating to mental health for our service users, in terms of both the practice and spirit of the law.

Kaneez has worked in the community for over 20 years, extensively in voluntary roles to give back to the communities of Leeds.  She has previously been a Chair of Governors at Hovingham Primary School, a Non-executive Director at East Leeds PCT and a Trustee for Catch Leeds. Currently, Kaneez is the Faith and Community Coordinator at Wellsprings Together. She is also a director of Primrose Consultancy Yorkshire. To honour her work for interfaith relations, particularly during the Covid-19 pandemic, Kaneez received an MBE in the Queens New Year’s Honours list of 2022.

Katy Wilburn, Non-executive Director

Katy’s role on the Board is to hold the Chief Executive and her executive team to account for the delivery of the organisation’s strategic aims and objectives.  She is a member of the Finance and Performance Committee and the Mental Health Legislation Committee. Katy is also the Trust’s Non-executive Director Champion for Sustainability.

By holding the executive directors to account she is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way.  She is also able to be assured that clinical quality controls, and systems of risk management and governance, are robust and implemented.

For the past 14 years, Katy has worked in the social housing sector, specialising in performance monitoring, service improvement and delivery redesign. She is currently the Head of Transformation for First Choice Homes in Oldham. She is also a Non-executive Director for another social housing provider based in the North-East, Thirteen Group, where she chairs the Customer Committee, ensuring the customer voice is central to the Group’s strategic decision making.

Katy’s personal motive for joining the Board was her teenage son, Sam, who was diagnosed with autism at the age of three. Alongside her professional expertise, Katy’s family also has 12 years of lived experience of a number of services similar to those delivered by the Trust.

Martin Wright, Non-executive Director (Chair of the Audit Committee and Deputy Chair of the Trust)

Martin’s role as a non-executive director is to hold the Chief Executive and the executive team to account for the delivery of the organisation’s strategic aims and objectives. He is the Chair of the Audit Committee and a member of the Finance and Performance Committee.

By holding the executive directors to account he is able to be assured that services are provided in the most safe, timely, equitable, efficient, effective and patient-centred way.  As the Chair of the Audit Committee, he ensures that the committee looks at the effectiveness of our governance (corporate and clinical), financial reporting, health and safety, risk management and audit processes and the Trust’s system of internal controls.

Martin was the Deputy Chief Financial Officer for DLA Piper International, one of the largest global law firms, where he was responsible for all aspects of financial reporting and control, including treasury, taxation and financial planning. He managed an international team of finance staff which provided support for more than 4,000 lawyers operating in more than 30 countries around the world.

Dr Sara Munro, Chief Executive

Sara leads the team of executive directors who, along with the chair and the non-executive directors, make up our Board of Directors. The Board is responsible for setting the strategic direction for the organisation.  Sara is also a senior leader within a wider group of chief executives and chief officers that come together to look at health and social care provision across Leeds and West Yorkshire.  Sara is the Senior Responsible Officer for Mental Health, Learning Disabilities and Autism within the West Yorkshire Health and Care Partnership and is the sector representative on the West Yorkshire Integrated Care Board.  She is also the executive lead on Workforce for the health and care partners in Leeds. Sara is a Trustee of The Workforce Development Trust and chair of the North East Yorkshire and Humber Mental Health, Learning Disability and Autism Provider Forum.

Sara’s passion is to improve the experience of service users and carers by ensuring we set the right objectives for our organisation which reflect the needs of our service users, carers and local communities. She will then make sure we provide the right support, including resources, for our staff to deliver the best possible mental health and learning disability services for the people we serve; that we monitor how well we are doing; and that we include service users, carers, communities and our staff in the decisions we make about our services.  Sara is also passionate about partnership working which can bring great benefits for the care we provide and is reflected in the wider roles she holds within the system.

Sara has been the Chief Executive since 2016.  She is a registered mental health nurse. Her clinical work was spent in inpatient mental health settings and she has worked across a range of NHS providers in the North West of England. Sara has a PhD which looked at attitudes of acute mental health nurses and their impact on service users’ experience of care.

Joanna Forster Adams, Chief Operating Officer

As Chief Operating Officer Joanna works with Trust staff, leaders and managers, together with partners and stakeholders across the Northern region, to deliver care across all of our services.  She leads on service development and integration, ensuring that we respond to changes in the needs of the people we serve, working alongside health and care statutory and voluntary colleagues. Joanna is also responsible for major service change and supporting people to encourage and enable improvement on an ongoing basis. At a West Yorkshire level, Joanna leads the Children and Young Peoples’ Service provider collaborative and plays an active role in the broader Mental Health, Learning Disability and Autism Programme.

As a very experienced Accountable Emergency Officer, Joanna has statutory responsibility for making sure we plan for, and respond to, an emergency or crisis. Joanna led our response to the Covid-19 pandemic and our Covid-19 vaccination programme. She is the Executive Lead for improving health equity and in 2025 launched the Trust’s first Improving Health Equity Strategic Plan, with an ambitious and determined programme of priorities and actions to address the widening equalities faced by the people we work with.

Joanna contributes to improving the experience of service users and carers by managing and leading on the delivery of high-quality care and services. She reports on what we are doing well and where we do not meet the standards of care, access or delivery which provides high quality care for our service users.  She, and her team, pay particular attention to the problems that directly affect service users and their carers and look for ways to improve the quality of what we do.

Joanna joined the Trust in July 2017. She was previously Executive Director of Operations for Mental Health and Community Services in the North West of England.   She has worked in the NHS since 1984 and has experience of clinical and corporate services in hospitals, community and mental health organisations in the North East of England.  She gained a Master’s in Business Administration from Durham University and is a graduate of the NHS Leadership Academy Nye Bevan programme.

Her motivation is drawn from the passion and determination shown by staff, stakeholders, service users and carers to drive improvement in mental health and learning disability care. With over 25 years as a senior NHS manager and leader, she aims to support staff to be the best they can be by prioritising their development, supporting their wellbeing, creating a culture of inclusion, and enabling people to do the right thing for the people who need our help.

Dawn Hanwell, Chief Financial Officer and Deputy Chief Executive

Dawn leads a number of departments which include finance and contracting, information management and technology, estates and facilities, and procurement (including mHabitat and the North of England Commercial Procurement Collaborative).

The functions she oversees make a significant contribution to the work of our Trust’s frontline staff, in order to support them to focus on working directly with service users and carers. These functions contribute by:

  • Looking after the finances and advising on what we can spend our resources on, including how to buy goods and services within the limits which we are set
  • Dealing with our commissioners to get the best possible income settlement to provide the services we deliver
  • Maintaining the estate to the best possible standard for delivering safe care and providing a good environment for staff
  • Maintaining and continuously improving the technology, tools and infrastructure which support our work on a daily basis.

Dawn was appointed to this post on 1 August 2012, having previously worked at our Trust as the Deputy Director of Finance between 2003 and 2007. Her previous role was as Director of Finance and Information at Barnsley Hospital NHS Foundation Trust.  She started her career in the NHS as a financial management trainee and has worked across a number of NHS organisations, mainly on the provider side but also briefly in commissioning and at the Department of Health. She has a wide range of experience mostly in finance but more recently managing estate and information.

Her first degree is in Theology and Religious Studies and she qualified as an accountant with the Chartered Institute of Public Finance Accountancy (CIPFA) in 1990.

Dr Chris Hosker, Medical Director

Chris has been our Medical Director since 1 August 2020. He is responsible for applying the best medical practice and the highest quality of care for our service users. He works closely with Nichola Sanderson, our Director of Nursing and Professions, and Joanna Forster Adams, our Chief Operating Officer, to oversee the quality improvement, regulation and delivery of our services and shape these to best meet future needs. Improving the quality of our clinical services in way that reflects the LYPFT STEEEP (safe, timely, efficient, equitable, effective and patient centred) quality framework is a key part of Chris’ role.

Chris studied medicine at Nottingham University and qualified in 2000 before moving to Leeds in 2001 to commence specialist training in psychiatry. During his psychiatric training he worked in a range of services across the region, also training briefly in a Crisis Service in Melbourne, Australia. While training he became a Member of the Royal College of Psychiatry, completed a Masters in Clinical Psychiatry and gained a Post Graduate Diploma in Mental Health Law.

He commenced his first consultant post in 2008, which was in the Leeds Liaison Psychiatry Service and developed a special interest in palliative care psychiatry, multi-disciplinary approaches to persistent physical symptoms and the psychological aspects of liver transplantation. He worked closely with the British Psycho-Oncology Society and has been the Academic Secretary for the Regional Division of the Royal College of Psychiatry.

In addition to his clinical interests, Chris also developed a particular focus on clinical leadership and the conditions for organisational improvement. He has held a variety of leadership positions within the Trust, including Associate Medical Director for Mental Health Legislation, Clinical Lead for Liaison Psychiatry and Lead Psychiatrist. He was also supported to enhance his leadership experience through the NHS Leadership Academy where he has completed the Shadow Board and Aspiring Medical Director Programmes as well as a Masters in Health Care Leadership. The latter culminated in a research dissertation on psychological safety in LYPFT. Chris is also the Clinical Chair for the Mental Health Transformation Board in Leeds and leads the Perinatal Mental Health Provider Collaborative across Yorkshire and Humber.

Darren Skinner, Director of People and Organisational Development

Darren was appointed as our Interim Director for People and Organisational Development (OD) on 10 May 2021 and was appointed substantively on 1 August 2022. Darren is responsible for leading our Workforce and OD Team to ensure they have the right support and structures in place, helping our workforce through Covid-19 recovery and overseeing the delivery of the Trust’s People Plan in which staff wellbeing and equality and inclusion continue to be key priorities.

Darren started his career as a nurse, working in adult intensive care and later neonatal and paediatric intensive care at Birmingham Children’s Hospital. He was an active and experienced local Royal College of Nursing (RCN) representative and went on to work for the RCN as a Regional Officer, covering healthcare across North London before embarking on his HR career.

As a senior human resources practitioner he has worked at Guy’s and St Thomas’ NHS Foundation Trust leading an employment relations team before going on to work for the City of London Police, ultimately as HR Director, followed by the British Transport Police.

He worked with the Government of Jersey as an Interim HR Director for the Health and Community Services department, supporting a significant change programme and the development of the ‘Jersey Care Model’, as well as advising the Minister for Health and Social Services on workforce and HR policy related issues. Darren’s most recent assignment was a significant staff engagement project with NHS Blood and Transplant before taking the role at LYPFT. He is also a Director for Skinner Consulting Ltd.

Nichola Sanderson, Director of Nursing and Professions

Nichola has over 20 years of experience in Mental Health Nursing, having joined LYPFT as Deputy Director of Nursing in 2017. Nichola has been the Director of Nursing and Professions for two years.

Nichola leads on the professional development and standards of staff within the Trust which covers Nursing, Allied Health Professionals (AHPs), Social Workers, and Psychology.  Her particular focus is to ensure that quality of care is of a high standard across the organisation, and she works closely with Dr Chris Hosker, our Medical Director, to oversee the current quality and delivery of our services and shapes these to best meet future needs. In addition, Nichola is our Director of Infection, Prevention and Control and plays a key role in keeping our service users and staff safe and free from the spread of infection. Nichola also has responsibility for patient safety and safeguarding.

Nichola graduated from the University of Manchester with a Higher National Diploma in Mental Health Nursing in 2002 and started her career as Mental Health Acute Ward Staff Nurse at Greater Manchester West NHS Foundation Trust. In 2009, she took up a post of Modern Matron at Pennine Care NHS Foundation Trust, before moving on to be a Nurse Consultant at Cumbria Partnership NHS Foundation Trust in 2011. In 2014, Nichola was appointed as the Associate Director of Nursing at Cumbria Partnership NHS Foundation Trust. She joined Leeds and York Partnership NHS Foundation Trust as Deputy Director of Nursing in April 2017. In this role Nichola worked closely with her operational and clinical colleagues to strengthen leadership across the organisation and embed clinical governance across the Trust. Nichola played a key part in the Trust’s response to the Covid-19 pandemic with a focus on keeping service users and staff safe.

In the two years as Director of Nursing and Professions, Nichola has overseen the implementation of the Patient Safety Incident Review Framework (PSIRF), which has changed how serious patient safety incidents are reviewed and how learning is shared across the organisation. In addition, Nichola has led on the sexual safety policy, ensuring our patients and staff are cared for in the safest possible environments. Her team continues to support nursing and AHP recruitment and retention, supporting our newly qualified staff to have the best experience possible at LYPFT, making us the employer of choice for those completing their university degree and throughout their career in the NHS.  Nichola is passionate about quality of care and patient safety, always striving to ensure that the nursing and AHP workforce are supported to have the right skills for their roles, enabling our staff to provide the highest quality of care to our patients, carers and families. Nichola is privileged to work with such committed staff who work continuously to improve the lives of our patients.

Anyone wanting to contact our directors can find their contact details on our Board of Directors page.

3.4 – Meetings of the Board of Directors

Our Board meets every other month with the exclusion of August and December although in 2024/25 the Board held one extraordinary private meeting in June. All meetings are held in public but items which are of a confidential nature (as defined by pre-determined criteria and in accordance with the Constitution) will be taken in a private session.

In 2024/25 the Board of Directors met on seven occasions. The table below shows directors’ attendance at those meetings. Attendance at Board meetings is also reported to the Council of Governors at each of its meetings.

Table 3A – Attendance at Board of Directors’ meetings during 2024/25

Non-executive directors
Name Meetings eligible to attend 30 May 2024 20 June 2024 (extraordinary) 25 July 2024 26 September 2024 28 November 2024 30 January 2025 27 March 2025
Zoe Burns-Shore 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Dr Frances Healey 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Cleveland Henry 7 Attendance Attendance Sent apologies during 2024/25 Attendance Attendance Attendance Attendance
Kaneez Khan MBE 7 Attendance Attendance Attendance Sent apologies during 2024/25 Sent apologies during 2024/25 Attendance Attendance
Merran McRae 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Katy Wilburn 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Martin Wright 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Executive directors
Name Meetings eligible to attend 30 May 2024 20 June 2024 (extraordinary) 25 July 2024 26 September 2024 28 November 2024 30 January 2025 27 March 2025
Dr Sara Munro 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Joanna Forster Adams 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Dawn Hanwell 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Dr Chris Hosker 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Nichola Sanderson 7 Attendance Attendance Attendance Attendance Attendance Attendance Attendance
Darren Skinner 7 Attendance Attendance Attendance Sent apologies during 2024/25 Attendance Attendance Attendance

3.5 – Evaluation of the Board of Directors

3.5.1 – The Board of Directors and members of the Board

Details relating to the evaluation of the members of the Board of Directors can be found in Part A section 2.2.3.2 of this Annual Report.

3.5.2 – Board committees

The Board’s committee structure is made up of the: Audit Committee, Quality Committee, Finance and Performance Committee, Workforce Committee, Mental Health Legislation Committee, Remuneration Committee, and Nominations Committee. Each of these committees receives secretariat support from the Corporate Governance Team.

This is a simple diagram showing how the Board of Directors is linked to seven different committees. The Board sits at the top, and underneath it are the Audit Committee, the Quality Committee, the Finance and Performance Committee, the Workforce Committee, the Mental Health Legislation Committee, the Nominations Committee, and the Remuneration Committee.

Evaluation of the Board sub-committees is carried out using an internal evaluation questionnaire, with the exception of the Audit Committee, which is evaluated using the Healthcare Financial Management Association’s (HFMA) NHS Audit Committee Effectiveness Checklist. The outcome is reviewed by the committee and a report on any proposed changes that may be required is made to the Board of Directors by the chair of the committee. If required, the Terms of Reference would be changed and ratified by the Board.

More information on each Board committee, including the number of meetings and individual director attendance, can be found on our Board Sub-Committees page.

3.6 – The Audit Committee

The Audit Committee is the primary governance and assurance committee for the Trust. It is a formal sub-committee of the Board of Directors.

The Audit Committee seeks high-level assurance and provides an independent and objective review on the effectiveness of our governance (corporate and clinical), health and safety and risk management processes and it assures the Board of Directors in respect of internal controls. It receives assurance from executive directors and other areas of the organisation through reports, both regular and bespoke. It validates the information it receives through the work of Internal Audit and External Audit, again through reports and attendance by key personnel at its meetings to present papers on specific matters. Assurance is also gained through the knowledge that non-executive directors bring from other areas of their work, not least their own specialist areas of expertise, visiting services, and talking to staff and governors.

The Audit Committee has responsibility for ensuring that, should our auditors (KPMG) carry out any non-audit work, their independence is maintained. The committee will do this by reviewing and approving the scope of the work and the fees charged prior to the work being undertaken.

The substantive membership of the Audit Committee is made up at any one time of three non-executive directors. During 2024/25, the following members served on the committee as substantive members: Martin Wright, who was the chair of the committee, Dr Frances Healey and Cleveland Henry. The other non-executive directors are invited to attend on an ad-hoc basis as and when they feel it is appropriate.

In regular attendance at committee meetings are the Chief Financial Officer, and the Associate Director for Corporate Governance. There is also representation from our external auditors (KPMG) and NHS Audit Yorkshire for internal audit and counter-fraud services.

The table below shows the number of Audit Committee meetings in 2024/25 and attendance by each non-executive director member.

Table 3B – Attendance at Audit Committee meetings in 2024/25

Substantive non-executive director members
Name Tuesday 16 April 2024 Tuesday 18 June 2024 Tuesday 16 July 2024 Tuesday 22 October 2024 Tuesday 21 January 2025
Martin Wright (chair of the committee) Attendance Attendance Attendance Attendance Attendance
Dr Frances Healey Attendance Attendance Attendance Attendance Attendance
Cleveland Henry Attendance Attendance Sent apologies during 2023/24 Attendance Attendance

During 2024/25 the Audit Committee fulfilled the role of the primary governance and assurance committee and carried out its role primarily through:

  • The approval of the work plans (annual and strategic) for internal audit and counter fraud
  • The approval of the work plan for the annual audit of the Annual Accounts and the Annual Report
  • Regular progress reports and annual reports from internal audit and counter fraud
  • Regular updates from the external auditors on current sector developments and their audit findings
  • ISA 260 report on the outcome of the annual audit of annual accounts
  • Assessing the effectiveness of external and internal audit by reviewing periodic reports from the auditors and monitoring the pre-agreed key performance indicators.

At its April 2024 meeting the committee agreed to recommend that the Council of Governors support the reappointment of KPMG as the Trust’s external auditors for an additional three years, with the option to extend this by up to two additional years as a direct award under the procurement framework. This was ratified by the Council of Governors at its meeting on 30 April 2024.

At its June 2024 meeting the committee reviewed the Annual Report, Annual Accounts, the Annual Governance Statement and the Head of Internal Audit Statement for 2023/24. It was assured in relation to each of these documents and recommended to the Board that they should be adopted.

A separate annual report for the Audit Committee is produced and submitted to the Board of Directors for assurance and is also submitted to the Council of Governors for information. This can be found on the Board Sub-Committees page.

Further information about the sufficiency of our internal control processes can be found in the Annual Governance Statement in Part A section 2.7 of this Annual Report.
Return to Contents

1.1 – The performance report (Overview of Performance)

4.1 – Composition of the Council of Governors

The Council of Governors is the body that gives the public a voice in helping to shape and influence the future of mental health and learning disability services provided by our Trust. It is made up of people who have been elected from and by our membership and who are representative of our constituencies. It also includes people appointed from a range of partner organisations. The Council of Governors is chaired by the Chair of the Trust, who ensures a link between the Council and the Board of Directors; the Deputy Chair of the Trust is also the Deputy Chair of the Council of Governors.

NHS England requires each foundation trust to have a Lead Governor. Les France’s term as Lead Governor ended on 8 November 2024 and Ian Andrews was elected as the new Lead Governor commencing on 9 November 2024 for a period of two years. The main duties of the Lead Governor are to: be a point of contact for governors; make a presentation at the Annual Members’ Meeting accounting for the work of the Council over the past year; and to be involved in the appraisal of the Chair of the Trust (with the Senior Independent Director) and the other non-executive directors (with the Chair of the Trust).

During 2024/25 no amendments were made to the composition of seats within our Council of Governors. The composition ensures the Council is representative of our members and the public. Table 4A shows the composition of seats within our Council of Governors.

Table 4A – Composition of our Council of Governors

Appointed or elected Constituency name Number of seats
Elected Public: Leeds 6
Elected Public: York and North Yorkshire 1
Elected Public: Rest of England and Wales 1
Elected Service User: Leeds 4
Elected Service User: York and North Yorkshire 1
Elected Carer: Leeds 3
Elected Carer: York and North Yorkshire 1
Elected Service User and Carer: Rest of the UK 1
Elected Clinical Staff: Leeds and York & North Yorkshire 4
Elected Non-Clinical Staff: Leeds and York & North Yorkshire 2
Appointed Director for Children and Families Programme, West Yorkshire and Harrogate ICS 1
Appointed Volition Leeds – mental health representative 1
Appointed Volition Leeds – learning disabilities representative 1
Appointed York Council for Voluntary Services 1
Appointed Leeds City Council 1
Appointed City of York Council 1
Appointed and elected Total 30

Governors are either elected or appointed to seats on the Council of Governors for a period of up to three years. Elected governors consist of public, service user, carer, and staff (clinical and non-clinical) governors. Appointed governors are nominated individuals from partner organisations. Elected governors can stand to be re-elected for three terms of office holding a seat for up to a maximum of nine years. Elections are carried out in accordance with the election rules in Annex 5 of our Constitution. Further details about the elections we have held during 2024/25 can be found below in section 4.2.1.

Appointed governors can also be on our Council for a maximum of nine years. This period is made up of three terms each of up to three years. Tables 4B and 4C list those governors that have been members on the Council of Governors during 2024/25.

Table 4B – Elected governors

Name Note Constituency Maximum term of office elected for Date appointed from Date term of office ends / ended Number of terms served
Leila Abadi-Bulmer Governors who stepped down early during 2024/25, before the end of their term of office Carer: Leeds 3 years 30.05.24 05.07.24 First
Ian Andrews Governors who were newly elected or re-elected part-way through 2024/25 Staff: Non-clinical 3 years 30.05.24 29.05.27 Second
Miranda Arieh Governors who were newly elected or re-elected part-way through 2024/25 Public: Leeds 3 years 30.05.24 29.05.27 First
Oliver Beckett Not applicable Public: Leeds 3 years 23.07.22 22.07.25 First
Nicola Binns Not applicable Staff: Clinical 3 years 27.03.23 26.03.26 First
Les France Not applicable Public: Leeds 3 years 23.07.22 22.07.25 Third
Rachel Gibala Not applicable Service User: Leeds 3 years 06.05.21 06.05.24 First
Oliver Hanson Not applicable Staff: Clinical 3 years 06.05.21 06.05.24 First
Gail Harrison Governors who were newly elected or re-elected part-way through 2024/25 Staff: Clinical 3 years 30.05.24 29.05.27 Second
Matthew Knight Governors who were newly elected or re-elected part-way through 2024/25 Public: York and North Yorkshire 3 years 30.05.24 29.05.27 Second
Nicola Lister Governors who were newly elected or re-elected part-way through 2024/25 Public: Leeds 3 years 30.05.24 29.05.27 First
Carole Myers Governors who were newly elected or re-elected part-way through 2024/25 Service User: Leeds 3 years 30.05.24 29.05.27 First
Ivan Nip Governors who were newly elected or re-elected part-way through 2024/25 Public: Leeds 3 years 30.05.24 29.05.27 Third
Peter Ongley Not applicable Carer: Leeds 3 years 27.03.23 26.03.26 First
Becky Oxley Not applicable Service User: Leeds 3 years 09.10.23 08.10.26 First
Amy Pratt Not applicable Staff: Clinical 3 years 27.03.23 26.03.26 First
Helen Pyne Governors who stepped down early during 2024/25, before the end of their term of office Public: Rest of England and Wales 3 years 30.05.24 02.07.24 First
Adam Redhead Governors who were newly elected or re-elected part-way through 2024/25 Staff: Clinical 3 years 30.05.24 29.05.27 First
Joseph Riach Governors who stepped down early during 2024/25, before the end of their term of office Service User: Leeds 3 years 30.05.24 03.08.24 Second
Jon Salway Not applicable Carer: Leeds 3 years 09.10.23 08.10.26 First
Martyn Sinclair Governors who stepped down early during 2024/25, before the end of their term of office Service User: Leeds 3 years 30.05.24 18.06.24 First
Madhulika Singh Governors who stepped down early during 2024/25, before the end of their term of office Public: Leeds 3 years 30.05.24 28.01.25 First
Anne Toone Governors who were newly elected or re-elected part-way through 2024/25 Staff: Non-clinical 3 years 30.05.24 29.05.27 First

Table 4C – Appointed governors

Name Note Constituency Maximum term of office elected for Date appointed from Date term of office ends / ended Number of Terms served
Councillor Ian Cuthbertson Not applicable City of York Council 3 years 19.06.23 18.06.26 First
Tessa Denham Governors who were re-appointed or newly appointed part-way through 2024/25 Volition – Leeds (learning disabilities representative) 3 years 11.04.24 10.04.27 First
Matthew Knight Governors who stepped down early during 2024/25, before the end of their term of office York Council for Voluntary Services 3 years 19.08.22 30.04.24 First
Gabriella Obeng Nyarko Not applicable Volition – Leeds (mental health representative) 3 years 24.01.23 23.01.26 First
Councillor Fiona Venner Not applicable Leeds City Council 3 years 13.06.24 12.06.27 Second

4.2 – Changes to the Council of Governors

During 2024/25 there were a number of changes to the individuals holding the position of governor on our Council of Governors. The Board of Directors would like to thank all those who either stepped down early from office or came to the end of their term of office and note the valuable contribution they made to the work of the Council. These are: Leila Abadi-Bulmer, Rachel Gibala, Oliver Hanson, Helen Pyne, Joseph Riach, Martyn Sinclair and Madhulika Singh.

4.2.1 – Elected governors

Elections are carried out in accordance with the election rules as set out in Annex 5 of the Trust’s Constitution (elected governors are in the constituencies set out in Table 4A). To be eligible to stand for election you must be a member of our Trust. Where a vacancy occurs in a constituency and the Trust agrees to hold an election, members in that constituency are invited to nominate themselves, and where more people stand for election than there are seats available it will be necessary to hold a ballot which is held on a first-past-the-post system of voting. In 2024/25 we held one round of elections in spring 2024.

4.2.1.1 – Election held in spring 2024

During spring 2024 an election was held to the Council of Governors. This was due to there being a number of vacant seats already on the Council caused either by governors stepping down early or because the seats had been vacant for some time. The following seats were included in the election:

Table 4D – Seats included in the spring 2024 election
Constituency Name of constituency Number of seats included in the election
Public Leeds 4
Public York and North Yorkshire 1
Public Rest of England and Wales 1
Carer Leeds 1
Carer York and North Yorkshire 1
Service user Leeds 3
Service user York and North Yorkshire 1
Service user and carer Rest of UK 1
Staff clinical Leeds and York & North Yorkshire 2
Staff non-clinical Leeds and York & North Yorkshire 2

This round of elections commenced on the 14 March 2024 and concluded on the 29 May 2024. We were successful in filling seats as follows:

Table 4E – Elected unopposed
Name Constituency elected to:
Leila Abadi-Bulmer Carer: Leeds
Miranda Arieh Public: Leeds
Matthew Knight Public: York and North Yorkshire
Nicola Lister Public: Leeds
Carole Myers Service user: Leeds
Ivan Nip Public: Leeds
Joseph Riach Service user: Leeds
Martyn Sinclair Service user: Leeds
Madhulika Singh Public: Leeds

For the Public: Rest of England and Wales, Staff: Clinical and Staff: Non-clinical constituencies we had more people stand than seats available and so we had to hold a ballot. The following governors were elected by ballot and turnout was 2% for Public: Rest of England and Wales, 11% for Staff: Clinical and 21% for Staff: Non-clinical.

Table 4F – Elected by ballot
Name Constituency elected to:
Ian Andrews Staff: Non-clinical
Gail Harrison Staff: Clinical
Helen Pyne Public: Rest of England and Wales
Adam Redhead Staff: Clinical
Anne Toone Staff: Non-clinical

At the end of the election, we still had three vacancies in the following constituencies:

  • Carer: York and North Yorkshire (one seat)
  • Service user: York and North Yorkshire (one seat)
  • Service user and carer: Rest of UK (one seat)

4.2.2 – Appointed governors

Appointed governors are nominated by those organisations we have identified as our partner organisations, for the purpose of the Council of Governors, and are set out in table 4A.

During 2024/25 there were two changes to our appointed governors. Matthew Knight stepped down during his first term of office and Tessa Denham commenced her first term of office as an appointed governor on the Council of Governors.

The Board of Directors would like to thank all the appointed governors it has worked with through the year for their hard work, supporting the development of the services we provide, and we would like to welcome those newly appointed to our Council.

4.3 – Meetings of the Council of Governors

During 2024/25 the Council of Governors held four formal business meetings. All general Council meetings are held in public, although items which are of a confidential nature (as defined by pre-determined criteria and in accordance with the Constitution) will be taken in a private session. Notice of public Council of Governors’ meetings along with the agenda and papers are published on our Council of Governors meetings page.
The governors also hold an Annual Members’ Meeting. This was held in person in July 2024. This is a public meeting, and members are encouraged to attend to hear more about the work of the Trust and the Council of Governors.

Table 4G below details the number of meetings attended by each governor during 2024/25, including the Annual Members’ Meeting. This is shown out of a maximum of five meetings. If a governor has either resigned from or joined the Council of Governors part-way through the financial year, the number of meetings they were eligible to attend has been amended to reflect this (those meeting dates which have been blanked out in the table indicate that a governor was not eligible to attend the meeting).

Table 4G – Number of meetings attended by each governor

 

Name Note Appointed (A) or elected (E) Number of business meetings eligible to attend 30 April 2024 2 July 2024 7 November 2024 4 February 2025 Attendance at the Annual Members Meeting – 30 July 2024
Leila Abadi-Bulmer Governors who stepped down during 2024/25, before the end of their term of office and as such may not have been eligible to attend all meetings E 1 A member was not eligible to attend the meeting Governors who sent apologies during 2024/25 A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Ian Andrews Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 4 Attendance Attendance Attendance Attendance Attendance
Miranda Arieh Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 3 A member was not eligible to attend the meeting Attendance Attendance Governors who sent apologies during 2024/25 Attendance
Oliver Beckett Not applicable E 4 Attendance Attendance Attendance Governors who sent apologies during 2024/25 Governors who sent apologies during 2024/25
Nicola Binns Not applicable E 4 Attendance Governors who sent apologies during 2024/25 Attendance Governors who sent apologies during 2024/25 Governors who sent apologies during 2024/25
Councillor Ian Cuthbertson Not applicable A 4 Attendance Attendance Attendance Governors who sent apologies during 2024/25 Attendance
Tessa Denham Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings A 4 Governors who sent apologies during 2024/25 Attendance Attendance Attendance Governors who sent apologies during 2024/25
Les France Not applicable E 4 Governors who sent apologies during 2024/25 Governors who sent apologies during 2024/25 Attendance Attendance Attendance
Rachel Gibala Not applicable E 1 Attendance A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Oliver Hanson Not applicable E 1 Governors who sent apologies during 2024/25 A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Gail Harrison Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 4 Attendance Attendance Attendance Attendance Attendance
Matthew Knight Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings A 1 Governors who sent apologies during 2024/25 A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Matthew Knight Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 4 A member was not eligible to attend the meeting Attendance Attendance Attendance Attendance
Nicola Lister Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 3 A member was not eligible to attend the meeting Governors who sent apologies during 2024/25 Attendance Attendance Attendance
Carole Myers Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 3 A member was not eligible to attend the meeting Attendance Governors who sent apologies during 2024/25 Attendance Attendance
Ivan Nip Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 4 Attendance Attendance Attendance Attendance Attendance
Gabriella Obeng Nyarko Not applicable A 4 Governors who sent apologies during 2024/25 Attendance Attendance Attendance Governors who sent apologies during 2024/25
Peter Ongley Not applicable E 4 Attendance Attendance Attendance Attendance Attendance
Becky Oxley Not applicable E 4 Attendance Attendance Governors who sent apologies during 2024/25 Attendance Attendance
Amy Pratt Not applicable E 4 Attendance Attendance Attendance Attendance Attendance
Helen Pyne Governors who stepped down during 2024/25, before the end of their term of office and as such may not have been eligible to attend all meetings E 1 A member was not eligible to attend the meeting Governors who sent apologies during 2024/25 A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Adam Redhead Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 3 A member was not eligible to attend the meeting Attendance Attendance Attendance Attendance
Joseph Riach Governors who stepped down during 2024/25, before the end of their term of office and as such may not have been eligible to attend all meetings E 2 Attendance Governors who sent apologies during 2024/25 A member was not eligible to attend the meeting A member was not eligible to attend the meeting Attendance
Jon Salway Not applicable E 4 Attendance Governors who sent apologies during 2024/25 Attendance Governors who sent apologies during 2024/25 Attendance
Martyn Sinclair Governors who stepped down during 2024/25, before the end of their term of office and as such may not have been eligible to attend all meetings E 0 A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting A member was not eligible to attend the meeting
Madhulika Singh Governors who stepped down during 2024/25, before the end of their term of office and as such may not have been eligible to attend all meetings E 2 A member was not eligible to attend the meeting Attendance Attendance A member was not eligible to attend the meeting Governors who sent apologies during 2024/25
Anne Toone Governors who were newly elected or appointed during 2024/25 and as such may not have been eligible to attend all meetings E 3 A member was not eligible to attend the meeting Attendance Attendance Governors who sent apologies during 2024/25 Attendance
Councillor Fiona Venner Not applicable A 4 Governors who sent apologies during 2024/25 Attendance Attendance Attendance Attendance

4.4 – Duties of the Council of Governors

The overarching role of the Council of Governors is to make our Trust publicly accountable for the services it provides.  It does this by representing the interests of members as a whole and those of the public.  It informs our forward plans and holds the non-executive directors (NEDs) to account, individually and collectively, for the performance of the Board.  Governors are not directors and the duty of holding the NEDs to account does not mean governors are responsible for the decisions taken by the Board of Directors (members of the Board of Directors, both executive and non-executive directors collectively, share corporate responsibility and liability for those decisions).

Further information about the work of the Board of Directors can be found in Part A section 3 of this Annual Report.

In addition, there are a number of other key statutory tasks the Council of Governors must also carry out.  These include:

  • Appointing (and if necessary, removing) the Chair of the Trust and non-executive directors
  • Approving the appointment of the Chief Executive
  • Appointing (and if necessary, removing) the external auditor
  • Receiving the Annual Report and Accounts, and the auditor’s report on these
  • Approving amendments to the Constitution
  • Taking decisions on significant transactions and on any changes to non-NHS income.

If during the course of the Board of Directors and the Council of Governors carrying out their respective duties, it becomes apparent that there is a dispute between the Council and the Board there is a formal dispute resolution process which is set out in the Constitution at Annex 7 paragraph 10.

To help governors carry out their role, the Board of Directors also has a number of statutory duties placed on it including sending a copy of the agenda of Board meetings to governors before each meeting and copies of minutes of meetings as soon as practicable after the meeting; and ensuring that governors have the skills and knowledge they require to undertake their role.

The Council will reserve certain matters to itself and will delegate others to specific committees and individuals. Details of this are set out in a document called Reservation of Powers to the Board of Directors and Council of Governors and Schedule of Decisions/Duties Delegated by the Board of Directors.

4.5 – Working together

The work of the Board of Directors and of the Council of Governors is closely aligned. The Chair of the Trust, supported by the Associate Director for Corporate Governance, provides a formal link between the two bodies and it is the Chair’s responsibility to ensure an appropriate flow of information.

The Council of Governors has a primary relationship with the non-executive directors (NEDs) who are encouraged wherever possible to attend Council meetings to get to know the governors better and to hear first-hand their views and those of members. One way in which this is further supported is through the annual Board to Council meeting. This private meeting includes a number of the Trust’s key strategic areas of focus on the agenda. This meeting further enhances the relationship between the Council and the NEDs and provides an opportunity for the governors to work more closely with NEDs and other members of the Board. Governors are also invited to observe a number of the Board sub-committee meetings and are encouraged to observe at least one public Board of Directors’ meeting each year. This provides further opportunity for the governors to witness the NEDs holding the executive directors to account for the performance of the Board.

The following table shows those Council meetings in 2024/25 that were attended by non-executive directors.

Table 4H – Attendance by non-executive directors at Council of Governors’ meetings

Name 30 April 2024 2 July 2024 7 November 2024 4 February 2025
Merran McRae Attendance Attendance Attendance Non-executive directors who sent apologies during 2024/25
Zoe Burns-Shore Non-executive directors who sent apologies during 2024/25 Attendance Attendance Non-executive directors who sent apologies during 2024/25
Dr Frances Healey Attendance Attendance Non-executive directors who sent apologies during 2024/25 Attendance
Cleveland Henry Non-executive directors who sent apologies during 2024/25 Non-executive directors who sent apologies during 2024/25 Attendance Attendance
Kaneez Khan Non-executive directors who sent apologies during 2024/25 Attendance Attendance Attendance
Katy Wilburn Attendance Attendance Non-executive directors who sent apologies during 2024/25 Attendance
Martin Wright Attendance Attendance Attendance Attendance

4.6 – Sub-committees of the Council of Governors

The Council of Governors may not delegate any of its responsibilities; however, it can choose to carry out its duties either through individual governors or through groups and committees.  In light of this, the Council of Governors has formed the Appointments and Remuneration Committee (a committee required in statute).  This committee reports formally to the Council of Governors.

  • The Appointments and Remuneration Committee – this committee reviews and makes recommendations to the Council of Governors regarding the appointments process for vacant posts within the non-executive director team and also sets the level of remuneration for NEDs.  Further information about the work of this committee during 2024/25 can be found in the Remuneration Report in Part A section 2.2 of this Annual Report.

4.7 The Register of Governors’ Interests

Under the provisions of the Constitution and as described in the provider licence, we are required to have a register of interests to formally record declarations of interests of members of the Council of Governors. The register will include details of all directorships and other relevant material interests which have been declared. It also asks governors to declare that they are of sound character and background to hold a position in public office.

On appointment and annually thereafter, members of the Council of Governors must declare any interests, which might place, or be seen to place them in a potential conflict of interest between their personal or private interest and those arising from their membership of the Council of Governors. Members of the Council of Governors are also required to declare any conflict or pecuniary interests that arise in the course of conducting business at each meeting. Each year governors will complete a new declaration of interest form to ensure the most up-to-date position is declared. These annual declarations are also reported to the Council of Governors.

The Register of Interests is maintained by the Associate Director for Corporate Governance and is available for inspection on the Trust’s website. The Associate Director for Corporate Governance can be contacted by telephone on 07815924185 or by email Clare Edwards.

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1.1 – The performance report (Overview of Performance)

5.1 – Our constituencies and eligibility to join

On 31 March 2025, the membership was 13,907. This has been steadily maintained throughout the year. The tables below illustrate the breakdown, by constituency, of the total number of members. We have three membership constituencies: public; service user and carer; and staff. A breakdown of these is shown at table 5A.

There are three public constituencies: Leeds; York and North Yorkshire and Rest of England and Wales. These constituencies are made up of a number of local government electoral areas. This is in accordance with the NHS Act 2006. If a person wants to join a public constituency the relevant one will be determined by the address at which they live.

The Service User and Carer Constituency is divided into five constituencies for the geographical areas of: Leeds; York and North Yorkshire and the rest of England and Wales. Again, these constituencies follow the local government electoral boundaries. Anyone who has used our services in the last 10 years or cares for someone who has used our services can join the Service User and Carer Constituency. An individual’s home address will determine which constituency they join.

The Staff Constituency is divided into two categories: Staff: Clinical and Staff: Non-clinical. Any individual who is employed by the Trust under a contract of employment will automatically become a member unless they opt out. In addition to those individuals directly employed by the Trust, people who exercise a function for the Trust may also choose to be a member of the Staff Constituency. Whether a person joins the clinical or the non-clinical class will be determined by national occupation codes.

Table 5A – Membership constituencies

Public constituency Service User and Carer constituency Staff constituency
Public: Leeds Service User: Leeds Clinical Staff: Leeds and York and; North Yorkshire
Public: York and North Yorkshire Service User: York and North Yorkshire Non-clinical Staff: Leeds and York and; North Yorkshire
Public: Rest of England and Wales Carer: Leeds
Carer: York and North Yorkshire
Service User and Carer: Rest of UK

5.2 – Number of members

Table 5B – Total membership by constituency as on 31 March 2025

Public constituency Number of members
Public: Leeds 6222
Public: York and North Yorkshire 1197
Public: Rest of England and Wales 1596
Total public members (Including 49 members outside England and Wales) 9064
Service User and Carer constituency Number of members
Service user: Leeds 455
Service user: York and North Yorkshire 65
Carer: Leeds 266
Carer: York and North Yorkshire 33
Service User and Carer: Rest of UK 74
Total service user and carer members 893
Staff constituency Number of members
Clinical staff: Leeds and York & North Yorkshire 3015
Non-clinical staff: Leeds and York & North Yorkshire 935
Total staff members 3950

Membership has maintained steady at 13,907 on 31 March 2025. These tables illustrate the breakdown, by constituency, of the total number of members.

5.3 – Developing a representative membership

Members of the public, staff, service users, their families and carers can join our Trust as a member. We are responsible for ensuring that our membership is representative of the people that the Trust could provide services to. The profile of the current membership in terms of ethnicity, gender and age continues to be broadly in line with that of the respective constituencies, with no significant deficits. A review of membership has been undertaken by the Trust and results from this confirmed that membership numbers remain high and representative.

5.4 – Membership recruitment and engagement

We value the contribution of our membership and our focus will be on qualitative rather than quantitative membership levels and engagement. The Council of Governors support planned development work of the membership database alongside ongoing engagement.

We have a varied approach to facilitating engagement between governors, members and the wider public. In particular, each year we hold our Annual Members’ Meeting. This not only incorporates the statutory annual meeting where the Council accounts for how it has carried out its duties on behalf of members, it also is an opportunity to celebrate the work carried out by the Trust during the year. Governors get the opportunity to meet with, talk to and hear from their constituents and the wider public. The Trust’s Annual Members’ Meeting was held on 30 July 2024. In 2025/26 we will continue to ensure that our governors are central to this event which allows them to engage with a diverse group of people.

5.5 – The membership office

The Membership Office is the initial point of contact for members to speak to someone within our Trust or with our governors. The office can be contacted by telephone on 07977 327628 or email the Membership inbox.
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6 – Our auditors

6.1 – External audit services

Our external audit service is provided by KPMG. They were appointed by our Council of Governors with effect from 1 October 2017 following a full tender process. Their tenure was initially for three years. This was extended by the Council for a further year until May 2021. It was extended again for a further year until May 2022. In January 2022, the Council agreed to extend their tenure for a further two years until June 2024. In April 2024, the Council of Governors agreed to reappoint KPMG for an additional three years, to June 2027.

All members of the KPMG audit team are independent of the Board of Directors and of staff members. Each year the audit team provides a statement in support of the requirements for their objectivity and independence to the Audit Committee. The auditors provide audit services in accordance with the Code of Audit Practice. This covers the opinion on the annual accounts and work to be satisfied whether the Trust has proper arrangements to secure value for money.

The cost of independent audits during 2024/25 is detailed in the table below:

Table 6A – Cost of statutory audits

Statutory audit (accounts and value for money responsibilities) £160,000
Total KPMG fees £160,000

6.2 – Internal audit services

Our internal audit and counter fraud services are provided by Audit Yorkshire. This is a specialist not-for-profit NHS provider of internal audit and counter fraud services.

On 1 June 2019 the Trust became a formal member of Audit Yorkshire. This provides a direct cost benefit, in terms of a highly competitive day rate. It also has the benefit of ‘buy-in’ and ownership with the ability to contribute to the strategic direction of the service and is fully aligned with the consolidation of back-office functions, as recommended by the Lord Carter review and NHS England.

The Internal Audit Team is led by Helen Higgs (CFIIA/CMI/CCFS). Helen is the Managing Director and Head of Internal Audit. During 2024/25 Helen has been supported by Jonathan Hodgson (FCCA), the Trust’s Internal Audit Manager. The remaining team of auditors and specialists is drawn from across Audit Yorkshire.

The scope of the work of internal audit is to review and evaluate the risk management, control, and governance arrangements that we have in place, focusing in particular on how these arrangements help us to achieve our objectives. The Head of Internal Audit Opinion is used by the Accounting Officer to support the Annual Governance Statement. This is achieved through a risk-based plan of work, agreed with management, and approved by the Audit Committee. Internal Audit is only one source of assurance, and it works closely with other assurance providers, such as external audit and local counter fraud services, to ensure that duplication is minimised, and a suitable breadth of assurance obtained.

Audit Yorkshire also offers additional services (e.g. CQC Well Led inspection preparation support, specialist consulting, data protection advice and HR Investigations) designed to add value and improve the organisations operations.

Audit Yorkshire provides services in line with the Public Sector Internal Audit Standards (April 2017). This was confirmed in our mandated external quality assessment (September 2024) where an outcome of ‘Fully Conforms’ was achieved. The external assessment is required every five years and was undertaken by the Chartered Institute of Public Finance and Accountancy (CIPFA).
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Part B – The Annual Accounts and Auditor’s Report

Independent Auditor’s report to the Council of Governors of Leeds and York Partnership NHS Foundation Trust

Report on the audit of the financial statements

Opinion

We have audited the f inancial statements of Leeds and York Partnership NHS Foundation Trust (“the Trust”) for the year ended 31 March 2025 which comprise the Statement of Comprehensive Income, Statement of Financial Position, Statement of Changes in Taxpayers’ Equity and Statement of Cash Flows, and the related notes, including the accounting policies in note 1.

In our opinion the financial statements:

  • give a true and fair view of the financial position of the Trust as at 31 March 2025 and of its income and expenditure for the year then ended; and
  • have been properly prepared in accordance with the accounting policies directed by NHS England with the consent of the Secretary of State in February 2025 as being relevant to NHS Foundation Trusts and included in the Department of Health and Social Care Group Accounting Manual 2024/25; and
  • have been prepared in accordance with the requirements of the National Health Service Act 2006 (as amended).
Basis for opinion

We conducted our audit in accordance with International Standards on Auditing (UK) (“ISAs (UK)”) and applicable law. Our responsibilities are described below. We have fulfilled our ethical responsibilities under, and are independent of the Trust in accordance with, UK ethical requirements including the FRC Ethical Standard. We believe that the audit evidence we have obtained is a sufficient and appropriate basis for our opinion.

Going concern

The Accounting Officer has prepared the financial statements on the going concern basis as they have not been informed by the relevant national body of the intention to either cease the Trust’s services or dissolve the Trust without the transfer of its services to another public sector entity. They have also concluded that there are no material uncertainties that could have cast significant doubt over its ability to continue as a going concern for at least a year from the date of approval of the financial statements (“the going concern period”).

In our evaluation of the Accounting Officer’s conclusions, we considered the inherent risks associated with the continuity of services provided by the Trust over the going concern period.

Our conclusions based on this work:

  • we consider that the Accounting Officer’s use of the going concern basis of accounting in the preparation of the financial statements is appropriate; and
  • we have not identified and concur with the Accounting Officer’s assessment that there is not, a material uncertainty related to events or conditions that, individually or collectively, may cast significant doubt on the Trust’s ability to continue as a going concern for the going concern period.

However, as we cannot predict all future events or conditions and as subsequent events may result in outcomes that are inconsistent with judgements that were reasonable at the time they were made, the above conclusions are not a guarantee that the Trust will continue in operation.

Fraud and breaches of laws and regulations – ability to detect
Identifying and responding to risks of material misstatement due to fraud

To identify risks of material misstatement due to fraud (“fraud risks”) we assessed events or conditions that could indicate an incentive or pressure to commit fraud or provide an opportunity to commit fraud. Our risk assessment procedures included:

  • Enquiring of management, the Audit Committee and internal audit as to the Trust’s high- level policies and procedures to prevent and detect fraud including the internal audit f unction, and the Trust’s channel for “whistleblowing”, as well as whether they have knowledge of any actual, suspected, or alleged f
  • Assessing the incentives for management to manipulate reported financial performance because of the need to achieve financial performance targets delegated to the Trust by NHS England
  • Reading Board and Audit Committee
  • Using analytical procedures to identify any unusual or unexpected
  • Reading the Trust’s accounting policies

We communicated identified fraud risks throughout the audit team and remained alert to any indications of fraud throughout the audit.

As required by auditing standards, and taking into account possible pressures to meet delegated targets, we performed procedures to address the risk of management override of controls in particular the risk that Trust management may be in a position to make inappropriate accounting entries. On this audit we did not identify a fraud risk related to revenue recognition due to the block nature of the funding provided to the Trust during the year. We therefore assessed that there was limited opportunity for the Trust to manipulate the income that was reported.

We also identified a fraud risk related to completeness of expenditure recognition, particularly in relation to year end accruals and pushing 2024-25 expenditure into 2025-26.

We performed procedures including:

  • Identifying journal entries and other adjustments to test based on risk criteria and comparing the identified entries to supporting documentation. These included unusual cash journals, journals posted by senior management personnel, and postings to reduce expenditure in March 2025.
  • Assessing whether the judgements made in making accounting estimates are indicative of a potential bias.
  • Inspecting a sample of expenditure items in the period after 31 March 2025, to determine whether expenditure has been recognised in the correct accounting
  • Performing a year-on-year comparison of a sample of the largest accruals in the prior year and current year and challenging management where the movement is not in line with our understanding of the entity.

We identified areas of laws and regulations that could reasonably be expected to have a material effect on the financial statements f rom our general sector experience and through discussion with the Accounting Officer and other management (as required by auditing standards) and discussed with the Accounting Officer and other management the policies and procedures regarding compliance with laws and regulations.

We communicated identified laws and regulations throughout our team and remained alert to any indications of non-compliance throughout the audit.

The potential effect of these laws and regulations on the financial statements varies considerably.

The Trust is subject to laws and regulations that directly affect the financial statements, including the financial reporting aspects of NHS legislation. We assessed the extent of compliance with these laws and regulations as part of our procedures on the related financial statement items.

Whilst the Trust is subject to many other laws and regulations, we did not identify any others where the consequences of non-compliance alone could have a material effect on amounts or disclosures in the financial statements.

Context of the ability of the audit to detect fraud or breaches of law or regulation

Owing to the inherent limitations of an audit, there is an unavoidable risk that we may not have detected some material misstatements in the financial statements, even though we have properly planned and performed our audit in accordance with auditing standards. For example, the further removed non-compliance with laws and regulations is f rom the events and transactions reflected in the financial statements, the less likely the inherently limited procedures required by auditing standards would identify it.

In addition, as with any audit, there remained a higher risk of non-detection of f raud, as f raud may involve collusion, forgery, intentional omissions, misrepresentations, or the override of internal controls. Our audit procedures are designed to detect material misstatement. We are not responsible for preventing non-compliance or fraud and cannot be expected to detect non- compliance with all laws and regulations.

Other information in the Annual Report

The Accounting Officer is responsible for the other information, which comprises the information included in the Annual Report, other than the financial statements and our auditor’s report thereon. Our opinion on the financial statements does not cover the other information and, accordingly, we do not express an audit opinion or, except as explicitly stated below, any form of assurance conclusion thereon.

Our responsibility is to read the other information and, in doing so, consider whether, based on our financial statements audit work, the information therein is materially misstated or inconsistent with the financial statements or our audit knowledge. Based solely on that work:

  • we have not identified material misstatements in the other information; and
  • in our opinion the other information included in the Annual Report for the financial year is consistent with the financial statements.
Remuneration and Staff Reports

In our opinion the parts of the Remuneration and Staff Reports subject to audit have been properly prepared, in all material respects, in accordance with the NHS Foundation Trust Annual Reporting Manual 2024/25.

Accounting Officer’s responsibilities

As explained more fully in the statement set out on page 92, the Accounting Officer is responsible for the preparation of financial statements that give a true and f air view. They are also responsible for: such internal control as they determine is necessary to enable the preparation of financial statements that are free from material misstatement, whether due to fraud or error; assessing the Trust’s ability to continue as a going concern, disclosing, as applicable, matters related to going concern; and using the going concern basis of accounting unless they have been informed by the relevant national body of the intention to either cease the services provided by the Trust or dissolve the Trust without the transfer of their services to another public sector entity.

Auditor’s responsibilities

Our objectives are to obtain reasonable assurance about whether the financial statements as a whole are free f rom material misstatement, whether due to fraud or error, and to issue our opinion in an auditor’s report. Reasonable assurance is a high level of assurance, but does not guarantee that an audit conducted in accordance with ISAs (UK) will always detect a material misstatement when it exists. Misstatements can arise from fraud or error and are considered material if, individually or in aggregate, they could reasonably be expected to influence the economic decisions of users taken on the basis of the financial statements.

A fuller description of our responsibilities is provided on the FRC’s website.

Report on the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources

Under the Code of Audit Practice, we are required to report if we identify any significant weaknesses in the arrangements that have been made by the Trust to secure economy, efficiency and effectiveness in its use of resources.

We have nothing to report in this respect.

Respective responsibilities in respect of our review of arrangements for securing economy, efficiency and effectiveness in the use of resources

As explained more fully in the statement set out on page 92, the Accounting Officer is responsible for ensuring that the Trust has put in place proper arrangements for securing economy, efficiency and effectiveness in its use of resources.

Under Section 62(1) and paragraph 1(d) of Schedule 10 of the National Health Service Act 2006 we have a duty to satisfy ourselves that the Trust has made proper arrangements f or securing economy, efficiency and effectiveness in its use of resources.

We are not required to consider, nor have we considered, whether all aspects of the Trust’s arrangements for securing economy, efficiency and effectiveness in its use of resources are operating effectively. We are also not required to satisfy ourselves that the Trust has achieved value for money during the year.

We planned our work and undertook our review in accordance with the Code of Audit Practice and related statutory guidance, having regard to whether the Trust had proper arrangement s in place to ensure financial sustainability, proper governance and to use information about costs and performance to improve the way it manages and delivers its services. Based on our risk assessment, we undertook such work as we considered necessary.

Statutory reporting matters

We are required by Schedule 2 to the Code of Audit Practice to report to you if :

  • we issue a report in the public interest under paragraph 3 of Schedule 10 of the National Health Service Act 2006; or
  • we make a referral to the Regulator under paragraph 6 of Schedule 10 of the National Health Service Act 2006 because we have reason to believe that the Trust, or a director or officer of the Trust, is about to make, or has made, a decision which involves or would involve the incurring of expenditure which is unlawful, or is about to take, or has taken, a course of action which, if pursued to its conclusion, would be unlawful and likely to cause a loss or def

We have nothing to report in these respects.

The purpose of our audit work and to whom we owe our responsibilities

This report is made solely to the Council of Governors of the Trust, as a body, in accordance with Schedule 10 of the National Health Service Act 2006. Our audit work has been undertaken so that we might state to the Council of Governors of the Trust, as a body, those matters we are required to state to them in an auditor’s report and for no other purpose. To the f ullest extent permitted by law, we do not accept or assume responsibility to anyone other than the Council of Governors of the Trust, as a body, for our audit work, for this report, or for the opinions we have formed.

Delay in certification and completion of the audit

As at the date of this audit report, we are unable to confirm that we have completed our work in respect of the trust accounts consolidation pack of the Trust for the year ended 31 March 2025 because we have not received confirmation from the NAO that the NAO’s audit of the Department of Health and Social Care accounts is complete.

Until we have completed this work, we are unable to certify that we have completed the audit of Leeds and York Partnership NHS Foundation Trust for the year ended 31 March 2025 in accordance with the requirements of Schedule 10 of the National Health Service Act 2006 and the NAO Code of Audit Practice.

Salma Younis
for and on behalf of KPMG LLP
Chartered Accountants
Leeds

25 June 2025

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Annual accounts

Foreword to the Accounts

These accounts, for the year ended 31 March 2025, have been prepared by Leeds and York
Partnership NHS Foundation Trust in accordance with paragraphs 24 and; 25 of Schedule 7 within the National Health Service Act 2006.

Signed: Dr Sara Munro
Date: 19 June 2025
Dr Sara Munro
Chief Executive

Download the Annual Accounts 2024 – 2025. Please note this Excel file is not accessible for some users. Please see below summaries for each account.

Statement of comprehensive income as at 31 March 2025

Income and Expenses
  • Operating income: £277,431,000 (2024: £256,902,000)
  • Operating expenses: £276,456,000 (2024: £258,572,000)
  • Operating surplus: £975,000 (2024: £(1,670,000))
Finance Costs
  • Finance income: £6,034,000 (2024: £6,414,000)
  • Finance expense – financial liabilities: £(2,536,000) (2024: £(5,176,000))
  • Finance expense – unwinding of discount on provisions: £(29,000) (2024: £(21,000))
  • PDC dividend payable: £(90,000) (2024: not listed)
  • Net finance income: £3,379,000 (2024: £1,217,000)
Other Gains
  • Gain/(loss) on disposal of assets: £2,000 (2024: £(5,000))
Surplus
  • Surplus from operations: £4,356,000 (2024: £(458,000))
  • Surplus for the year: £4,356,000 (2024: £(458,000))
Other Comprehensive Income
  • Revaluation gains on intangible assets: £68,000 (2024: £44,000)
  • Revaluation gains on property, plant, and equipment: £1,064,000 (2024: £434,000)
  • Total other comprehensive income: £1,132,000 (2024: £478,000)
Total Comprehensive Income
  • Total comprehensive income for the year: £5,488,000 (2024: £20,000)

Statement of financial position as at 31 March 2025

Non-current assets (2025 / 2024)
  • Intangible assets: £1,737,000 / £1,035,000
  • Property, plant and equipment: £72,222,000 / £66,259,000
  • Trade and other receivables: £8,546,000 / £7,890,000
  • Total non-current assets: £82,505,000 / £75,184,000
Current assets
  • Inventories: £65,000 / £64,000
  • Trade and other receivables: £13,386,000 / £12,087,000
  • Non-current assets for sale: £0 / £0
  • Cash and cash equivalents: £123,686,000 / £116,678,000
  • Total current assets: £137,137,000 / £128,829,000
Current liabilities
  • Trade and other payables: £47,339,000 / £41,884,000
  • Borrowings: £7,428,000 / £6,709,000
  • Provisions: £3,071,000 / £2,102,000
  • Other liabilities: £7,932,000 / £5,237,000
  • Total current liabilities: £65,770,000 / £55,932,000
Total assets less current liabilities
  • £153,872,000 / £148,081,000
Non-current liabilities
  • Borrowings: £13,898,000 / £20,047,000
  • Provisions: £4,844,000 / £6,564,000
  • Total non-current liabilities: £18,742,000 / £26,611,000
Total assets employed
  • £135,130,000 / £121,470,000
Financed by (Taxpayers’ Equity)
  • Public dividend capital: £46,422,000 / £38,250,000
  • Revaluation reserve: £7,605,000 / £6,772,000
  • Other reserves: £(651,000) / £(651,000)
  • Income and expenditure reserve: £81,754,000 / £77,099,000
  • Total taxpayers’ equity: £135,130,000 / £121,470,000

Statement of changes in taxpayers’ equity

Opening Balance at 1 April 2024
  • Public Dividend Capital: £38,250
  • Revaluation Reserve: £6,772
  • Other Reserves: -£651
  • Income and Expenditure Reserve: £77,099
  • Total Taxpayers’ Equity: £121,470
Movements During the Year
  • Surplus for the year: £4,356 (added to Income and Expenditure Reserve)
  • Revaluation gains and impairment losses on intangible assets: £68 (added to Revaluation Reserve)
  • Revaluation gains and impairment losses on property, plant and equipment: £1,064 (added to Revaluation Reserve)
  • Public dividend capital received: £8,172 (added to Public Dividend Capital)
  • Transfers in respect of assets disposed of: £1 (moved from Revaluation Reserve to Income and Expenditure Reserve)
  • Transfer of excess depreciation: £298 (moved from Revaluation Reserve to Income and Expenditure Reserve)
Subtotal Movement in Year
  • Public Dividend Capital: £8,172
  • Revaluation Reserve: £833
  • Other Reserves: £0
  • Income and Expenditure Reserve: £4,655
  • Total Movement: £13,660
Closing Balance at 31 March 2025
  • Public Dividend Capital: £46,422
  • Revaluation Reserve: £7,605
  • Other Reserves: -£651
  • Income and Expenditure Reserve: £81,754
  • Total Taxpayers’ Equity: £135,130
Opening Balance at 1 April 2023
  • Public Dividend Capital: £36,626
  • Revaluation Reserve: £6,575
  • Other Reserves: -£651
  • Income and Expenditure Reserve: £88,392
  • Total Taxpayers’ Equity: £130,942
Movements During the Year
  • Application of IFRS 16 to PFI liability: -£11,116 (deducted from Income and Expenditure Reserve)
  • Surplus for the year: -£458 (deducted from Income and Expenditure Reserve)
  • Revaluation gains and impairment losses on intangible assets: £44 (added to Revaluation Reserve)
  • Revaluation gains and impairment losses on property, plant and equipment: £434 (added to Revaluation Reserve)
  • Public dividend capital received: £1,624 (added to Public Dividend Capital)
  • Transfers in respect of assets disposed of: £1 (moved from Revaluation Reserve to Income and Expenditure Reserve)
  • Transfer of excess depreciation: £280 (moved from Revaluation Reserve to Income and Expenditure Reserve)
Subtotal Movement in Year
  • Public Dividend Capital: £1,624
  • Revaluation Reserve: £197
  • Other Reserves: £0
  • Income and Expenditure Reserve: -£11,293
  • Total Movement: -£9,472
Closing Balance at 31 March 2024
  • Public Dividend Capital: £38,250
  • Revaluation Reserve: £6,772
  • Other Reserves: -£651
  • Income and Expenditure Reserve: £77,099
  • Total Taxpayers’ Equity: £121,470
Description of Reserves:

a) Public dividend capital represents in substance, the Secretary of State for Health’s ‘equity’ investment in the Trust. When the Trust’s predecessor NHS Trust was established, the amount of PDC provided to it equated to the initial net assets of the Trust. The PDC balance is usually a constant amount but can change occasionally where the Trust receives additional PDC (usually to fund capital investment) or is asked to repay an element to the Secretary of State.

b) The revaluation reserve is used to record revaluation gains/losses and impairment reversals on property, plant and equipment that are recognised in other comprehensive income. An annual transfer is made from the reserve to retained earnings of amounts representing the excess of current cost depreciation over historic cost depreciation for each item of PPE. When an asset is sold or otherwise disposed of, any remaining revaluation reserve balance for the asset is transferred to Retained Earnings. The balance in the reserve is wholly in respect of property, plant and equipment.

c) Other reserves relates to the write off of an asset which was included in the original NHS Trust’s asset base at inception.

d) The Trust’s surplus or deficit for the year is recognised in the Income and Expenditure Reserve, together with any other gain or loss for the financial year that is not recognised in any other reserve.

Statement of cash flows as at 31 March

Cash Flows from Operating Activities
Operating surplus from continuing operations:
  • 2025: £975
  • 2024: £(1,670)
Non-cash income and expense:
Depreciation and amortisation:
    • 2025: £7,657
    • 2024: £6,929
Impairments and reversals:
    • 2025: £419
    • 2024: £2,535
Income recognised in respect of capital donations:
    • 2025: £(24)
    • 2024: £0

Changes in working capital:

(Increase)/decrease in trade and other receivables:
    • 2025: £(2,041)
    • 2024: £(159)
(Increase)/decrease in inventories:
    • 2025: £(1)
    • 2024: £(25)
Increase/(decrease) in trade and other payables:
    • 2025: £(671)
    • 2024: £302

Increase/(decrease) in other liabilities:

    • 2025: £2,695
    • 2024: £(2,521)
Increase/(decrease) in provisions:
      • 2025: £(955)
      • 2024: £(3,840)
Net cash generated from operations:
  • 2025: £8,054
  • 2024: £1,551
Cash Flows from Investing Activities
Interest received:
  • 2025: £6,105
  • 2024: £6,302
Purchase of intangible assets:
  • 2025: £(1,854)
  • 2024: £(253)
Purchase of property, plant and equipment:
  • 2025: £(4,633)
  • 2024: £(6,867)
Sales of property, plant and equipment:
  • 2025: £3
  • 2024: £11
Net cash used in investing activities:
  • 2025: £(379)
  • 2024: £(807)
Cash Flows from Financing Activities
Public dividend capital received:
  • 2025: £8,172
  • 2024: £1,624
Capital element of PFI obligations:
  • 2025: £(6,102)
  • 2024: £(5,435)
Interest element of PFI obligations:
  • 2025: £(1,580)
  • 2024: £(1,978)
Capital element of lease liability repayments:
  • 2025: £(913)
  • 2024: £(794)
Interest element of lease liability repayments:
  • 2025: £(169)
  • 2024: £(168)
PDC dividend (paid)/refunded:
  • 2025: £(75)
  • 2024: £311
Net cash used in financing activities:
  • 2025: £(667)
  • 2024: £(6,440)
Cash and Cash Equivalents

Net increase/(decrease) in cash and cash equivalents:

  • 2025: £7,008
  • 2024: £(5,696)
Cash and cash equivalents at 1 April:
  • 2025: £116,678
  • 2024: £122,374
Cash and cash equivalents at 31 March:
  • 2025: £123,686
  • 2024: £116,678

Reconciliation of Statement of Financial Position to working balances adjustment in Cash Flow

Receivables

(Increase)/decrease in receivables as per SOFP:

  • 2024/25: £(1,955)
  • 2023/24: £40

Adjustments for receivables movements not related to income and expenditure:

  • Increase/(decrease) in capital receivables:
    • 2024/25: Not applicable
    • 2023/24: £112
  • Financing transactions:
    • 2024/25: £(86)
    • 2023/24: £(311)

(Increase)/decrease in receivables adjusted for non-income and expenditure items:

  • 2024/25: £(2,041)
  • 2023/24: £(159)
Payables

Increase/(decrease) in payables per SOFP:

  • 2024/25: £5,455
  • 2023/24: £(1,319)

Adjustments for payables movements not related to income and expenditure:

  • (Increase)/decrease in capital payables:
    • 2024/25: £(6,126)
    • 2023/24: £1,621
  • Financing transactions:
    • 2024/25: Not applicable
    • 2023/24: Not applicable

Increase/(decrease) in payables adjusted for non-income and expenditure items:

  • 2024/25: £(671)
  • 2023/24: £302
Other Liabilities

Increase/(decrease) in other liabilities per SOFP:

  • 2024/25: £2,695
  • 2023/24: £(2,521)

Adjustments for other liabilities movements not related to income and expenditure:

  • 2024/25: £2,695
  • 2023/24: £(2,521)
Provisions

Increase/(decrease) in provisions per SOFP:

  • 2024/25: £(751)
  • 2023/24: £(3,799)

Adjustments for provisions movements:

  • Movement in provisions recognised in capital rather than revenue:
    • 2024/25: £(175)
    • 2023/24: £(20)
  • Unwinding of discount on provisions:
    • 2024/25: £(29)
    • 2023/24: £(21)

Increase/(decrease) in provisions for non-income and expenditure items:

  • 2024/25: £(955)
  • 2023/24: £(3,840)
Capital Payables Movement

Opening capital payables:

  • 2024/25: £(2,295)
  • 2023/24: £(3,916)

Closing capital payables:

  • 2024/25: £(8,421)
  • 2023/24: £(2,295)

Change in capital payables in-year:

  • 2024/25: £6,126
  • 2023/24: £(1,621)

Notes to the accounts

The principal activity of the Trust is to provide excellent quality mental health and learning disability care that supports people to achieve the very best that they can for their health and wellbeing. The Trust’s registered address is St Mary’s House, Main House, St Mary’s Road, Potternewton, Leeds LS7 3JX.

1 – Accounting policies

NHS England has directed that the financial statements of the Leeds and York Partnership NHS Foundation Trust (LYPFT) shall meet the accounting requirements of the Department of Health and Social Care Group Accounting Manual (GAM), which shall be agreed with HM Treasury. Consequently, the following financial statements have been prepared in accordance with the GAM 2024/25 issued by the Department of Health and Social Care. The accounting policies contained in the GAM follow International Financial Reporting Standards to the extent that they are meaningful and appropriate to the NHS, as determined by HM Treasury, which is advised by the Financial Reporting Advisory Board. Where the GAM permits a choice of accounting policy, the accounting policy that is judged to be most appropriate to the particular circumstances of LYPFT for the purpose of giving a true and fair view has been selected. The particular policies adopted are described below. These have been applied consistently in dealing with items considered material in relation to the accounts.

In accordance with IAS1, the accounts are prepared on a going concern basis unless management either intends to apply to the Secretary of State for the dissolution of the NHS foundation trust without the transfer of the services to another entity, or has no realistic alternative but to do so.
After making enquiries, the directors have a reasonable expectation that the services provided by Leeds and York Partnership NHS Foundation Trust will continue to be provided for the foreseeable future. For this reason, the directors have adopted the going concern basis in preparing the accounts, following the definition of going concern in the public sector adopted by HM Treasury’s Financial Reporting Manual.

1.1 – Accounting convention

The accounts have been prepared under the historical cost convention modified to account for the revaluation of property, plant and equipment and intangible assets. For specialised operational property the modern equivalent asset valuation method has been used.

1.2 – Segmental reporting

Operating segments are reported in a manner consistent with the internal reporting provided to the chief operating decision maker. The chief operating decision maker, who is responsible for allocating resources and assessing performance of the operating segments, has been identified as the Board of Directors.

1.3 – Expenditure on employee benefits
Short term employee benefits

Salaries, wages and employment related payments such as social security and the apprenticeship levy are recognised in the period in which the service is received from employees. The cost of annual leave entitlement earned but not taken by employees at the end of the period is recognised in the accounts to the extent that employees are permitted to carry-forward leave into the following year.

1.4 – Pension costs

Past and present employees are covered by the provisions of the two NHS Pension Schemes. Details of the benefits payable and rules of the Schemes can be found on the NHS Pensions website.

Both are unfunded defined benefit schemes that cover NHS employers, GP practices and other bodies, allowed under the direction of the Secretary of State for Health and Social Care in England and Wales. They are not designed to be run in a way that would enable NHS bodies to identify their share of the underlying scheme assets and liabilities. Therefore, each scheme is accounted for as if it were a defined contribution scheme: the cost to the NHS body of participating in each scheme is taken as equal to the contributions payable to that scheme for the accounting period.

Employers pension cost contributions are charged to operating expenses as and when they become due. Additional pension liabilities arising from early retirements are not funded by the scheme except where the retirement is due to ill-health. The full amount of the liability for the additional costs is charged to the operating expenses at the time the Trust commits itself to the retirement, regardless of the method of payment.

In order that the defined benefit obligations recognised in the financial statements do not differ materially from those that would be determined at the reporting date by a formal actuarial valuation, the FReM requires that “the period between formal valuations shall be four years, with approximate assessments in intervening years”. An outline of these follows.

a) Full actuarial (funding) valuation

The purpose of this valuation is to assess the level of liability in respect of the benefits due under the scheme (taking into account its recent demographic experience), and to recommend the contribution rates payable by employers and employees.

The latest actuarial valuation undertaken for the NHS Pension Scheme was completed as at 31 March 2020. The results of this valuation set the employer contribution rate payable from 1 April 2024 at 23.7% of pensionable pay (previously 20.6%). The core cost cap cost of the scheme was calculated to be outside of the 3% cost cap corridor as at 31 March 2020. However, when the wider economic situation was taken into account through the economic cost cap cost of the scheme, the cost cap corridor was not similarly breached. As a result, there was no impact on the member benefit structure or contribution rates.

Employers and employee contribution rates may be varied from time to time, as above, to reflect changes in the scheme’s liabilities. In 2024/25 employee contributions are tiered depending on salary and range from 5.2% to 12.5%. Employer contributions for 2024/25 were 23.78%, including the administration levy (20.68% in 2024/25).

b) Accounting valuation

A valuation of scheme liability is carried out annually by the scheme actuary (currently the Government Actuary’s Department) as at the end of the reporting period. This utilises an actuarial assessment for the previous accounting period in conjunction with updated membership and financial data for the current reporting period, and is accepted as providing suitably robust figures for financial reporting purposes. The valuation of the scheme liability as at 31 March 2025, is based on valuation data as at 31 March 2024, updated to 31 March 2025 with summary global member and accounting data. In undertaking this actuarial assessment, the methodology prescribed in IAS 19, relevant FReM interpretations, and the discount rate prescribed by HM Treasury have also been used.

The latest assessment of the liabilities of the scheme is contained in the report of the scheme actuary, which forms part of the annual NHS Pension Scheme Accounts. These accounts can be viewed on the NHS Pensions website and are published annually. Copies can also be obtained from The Stationery Office.

c) Scheme provisions

In 2023/24 the NHS pension scheme provided defined benefits, which are summarised below. The list is an illustrative guide only, and is not intended to detail all the benefits provided by the scheme or the specific conditions that must be met before these benefits can be obtained:

Annual Pensions

The annual pension under the 1995 section of the scheme is based on 1/80th of the best of the last three years pensionable pay for each year of service and for the 2008 section it is based on 1/60th of reckonable pay per year of membership. Further changes to the scheme came into effect from 1 April 2015, which mean that the scheme is now based on average salary rather than final salary, with an accrual rate of 1/54th.

With effect from 1 April 2008 members can choose to give up some of their annual pension for an additional tax free lump sum, up to a maximum amount permitted under HMRC rules. This is known as pension commutation.

Members who are practitioners as defined by the scheme regulations have their annual pensions based upon total pensionable earnings over the relevant pensionable service.

Pensions Indexation

Annual increases are applied to pension payments at rates defined by the Pensions (Increase) Act 1971, and from 2011/12, are based on changes in consumer prices (CPI) in the twelve months ending 30 September in the previous calendar year.

Ill-health retirement

Early payment of a pension, with enhancement in certain circumstances, is available to members of the scheme who are permanently incapable of fulfilling their duties effectively through illness or infirmity.

Death benefits

A death gratuity of twice final year’s pensionable pay for death in service, and five times their annual pension for death after retirement is payable.

Additional voluntary contributions (AVCs)

Members can purchase additional service in the NHS pension scheme and contribute to money purchase AVC’s run by the scheme’s approved providers or by other free standing additional voluntary contribution (FSAVC) providers.

Transfer between funds

Scheme members have the option to transfer their pension between the NHS pension scheme and another scheme when they move into or out of NHS employment.

Preserved benefits

Where a scheme member ceases NHS employment with more than two years service, they can preserve their accrued NHS pension for payment when they reach retirement age.

1.41 – Alternative pension scheme

From 1 August 2013 (deferred to 1 October 2013), Leeds and York Partnership NHS Foundation Trust offers an alternative pension scheme to all employees who are not eligible to be members of the NHS pension scheme at the Trust. This includes employees who are members of the NHS pension scheme through another role outside of the Trust and those that are not eligible to join the NHS pension scheme.

Every three years all eligible employees are auto-enrolled in either the NHS or alternative pension scheme. The auto-enrolment exercise was carried out in October 2022 and following this process, all employees who meet the criteria for the alternative pension scheme are enrolled each month on a continuous basis, unless they specifically opt out.

The alternative pension scheme is a defined contribution scheme operated by the National Employment Savings Trust (NEST). Employee and employer contribution rates are a combined minimum of 8% (with a minimum 3% being contributed by the Trust).

1.5 – Income recognition

Income is accounted for by applying the accruals convention. The main source of income for Leeds and York Partnership NHS Foundation Trust is from commissioners in respect of healthcare services provided under local agreements (NHS Contracts). Where income is received for a specific activity, which is to be delivered in the following financial year, that income is deferred. Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.

1.51 – Revenue from contracts with customers

Where income is derived from contracts with customers, it is accounted for under IFRS 15. The GAM expands the definition of a contract to include legislation and regulations, which enables an entity to receive cash or another financial asset that is not classified as a tax by the Office of National Statistics (ONS).

Revenue in respect of goods/services provided is recognised when (or as) performance obligations are satisfied by transferring promised goods/services to the customer and is measured at the amount of the transaction price allocated to those performance obligations. At the year end, the Trust accrues income relating to performance obligations satisfied in that year. Where the Trust’s entitlement to consideration for those goods or services is unconditional a contract receivable will be recognised. Where entitlement to consideration is conditional on a further factor other than the passage of time, a contract asset will be recognised. Where consideration received or receivable relates to a performance obligation that is to be satisfied in a future period, the income is deferred and recognised as a contract liability.

1.52 – Revenue from NHS contracts

The main source of income for the Trust is contracts with commissioners for health care services. Funding envelopes are set at an Integrated Care System (ICS) level. The majority of the Trust’s NHS income is earned from NHS commissioners under the NHS Payment Scheme (NHSPS). The NHSPS sets out rules to establish the amount payable to trusts for NHS-funded secondary healthcare.

Aligned payment and incentive contracts form the main payment mechanism under the NHSPS. In 2024/25 API contracts contain both a fixed and variable element. Under the variable element, providers earn income for elective activity (both ordinary and day case), out-patient procedures, out-patient first attendances, diagnostic imaging and nuclear medicine, and chemotherapy delivery activity. The precise definition of these activities is given in the NHSPS. Income is earned at NHSPS prices based on actual activity. The fixed element includes income for all other services covered by the NHSPS assuming an agreed level of activity with ‘fixed’ in this context meaning not varying based on units of activity. Elements within this are accounted for as variable consideration under IFRS 15 as explained below.

The Trust also receives income from commissioners under Commissioning for Quality Innovation (CQUIN) schemes. Delivery under these schemes is part of how care is provided to patients. As such CQUIN payments are not considered distinct performance obligations in their own right; instead they form part of the transaction price for performance obligations under the overall contract with the commissioner and accounted for as variable consideration under IFRS 15. Payment for CQUIN on non-elective services is included in the fixed element of API contracts with adjustments for actual achievement being made at the end of the year. Where the relationship with a particular integrated care board is expected to be a low volume of activity (annual value below £0.5m), an annual fixed payment is received by the provider as determined in the NHSPS documentation. Such income is classified as ‘other clinical income’ in these accounts.

1.53 – Revenue from research contracts

Where research contracts fall under IFRS 15, revenue is recognised as and when performance obligations are satisfied. For some contracts, it is assessed that the revenue project constitutes one performance obligation over the course of the multi-year contract. In these cases it is assessed that the Trust’s interim performance does not create an asset with alternative use for the Trust, and the Trust has an enforceable right to payment for the performance completed to date. It is therefore considered that the performance obligation is satisfied over time, and the Trust recognises revenue each year over the course of the contract. Some research income alternatively falls within the provisions of IAS 20 for government grants.

1.54 – Mental health provider collaboratives

NHS led provider collaboratives for specialised mental health, learning disability and autism services involve a lead NHS provider taking responsibility for managing services, care pathways and specialised commissioning budgets for a population. As lead provider in West Yorkshire for Children’s and Young People Mental Health Services, and Adult Eating Disorders, Leeds and York Partnership NHS Foundation Trust is accountable to NHS England and as such recognises the income and expenditure associated with the commissioning of services from other providers in these accounts. Where the Trust is the provider of commissioned services, this element of income is recognised in respect of the provision of services, after eliminating internal transactions.

1.55 – Revenue grants and other contributions to expenditure

Government grants are grants from government bodies other than income from commissioners or Trusts for the provision of services. Where a grant is used to fund revenue expenditure it is taken to the Statement of Comprehensive Income to match that expenditure. Where the grant is used to fund capital expenditure, it is credited to the consolidated statement of comprehensive income once conditions attached to the grant have been met. Donations are treated in the same way as government grants.

The value of the benefit received when accessing funds from the Government’s apprenticeship service is recognised as income at the point of receipt of the training service. Where these funds are paid directly to an accredited training provider, from the Trust’s Digital Apprenticeship Service (DAS) account held by the Department for Education, the corresponding notional expense is also recognised at the point of recognition for the benefit.

1.56 – Other income

Income from the sale of non-current assets is recognised only when all material conditions of sale have been met, and is measured as the sums due under the sale contract.

1.6 – Expenditure on goods and services

Expenditure on goods and services is recognised when, and to the extent that they have been received, and is measured at the fair value of those goods and services. Expenditure is recognised in operating expenses except where it results in the creation of a non-current asset such as property, plant and equipment.

1.61 – Property, plant and equipment
Recognition

Property, plant and equipment is capitalised if:

  • it is held for use in delivering services or for administrative purposes;
  • it is probable that future economic benefits will flow to, or service potential will be supplied to, the Leeds and York Partnership NHS Foundation Trust;
  • it is expected to be used for more than one financial year;
  • the cost of the item can be measured reliably; and if any of the following apply:
  • the item has cost of at least £5,000;
  • collectively, a number of items have a cost of at least £5,000 and individually have a cost of more than £250, where the assets are functionally interdependent, they had broadly simultaneous purchase dates, are anticipated to have simultaneous disposal dates and are under single managerial control; or
  • items form part of the initial equipping and setting-up cost of a new building, ward or unit, irrespective of their individual or collective cost.

The finance costs of bringing property, plant and equipment into use are not capitalised.

Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

1.62 – Measurement
Valuation

All property, plant and equipment are measured initially at cost, representing the costs directly attributable to acquiring or constructing the asset and bringing it to the location and condition necessary for it to be capable of operating in the manner intended by management.

Land and buildings used for the Trust’s purposes are stated in the Statement of Financial Position at their revalued amounts being the fair value at the date of revaluation less any subsequent accumulated depreciation and impairment losses. In accordance with IFRS and NHS policy, a full revaluation is performed at least every five years, with an interim revaluation in the third year after the full revaluation. An impairment review is undertaken in all other years. The Trust believes that this is sufficiently regular to ensure that carrying amounts are not materially different from those that would be determined at the end of the reporting period. Fair values are determined as follows:

  • Land and non-specialised buildings: Valued at market value for existing use
  • Specialised buildings: Valued using depreciated replacement cost, based on providing a modern equivalent asset
  • Non-operational land and buildings: Valued at fair value, based on alternative use.

Professional valuations are carried out by the District Valuers of the Revenue and Customs Government Department. These valuations are carried out in accordance with the Royal Institute of Chartered Surveyors (RICS) Appraisal and Valuation manual. A valuation was last undertaken as at 31 March 2025 and the assets were reviewed for impairment using the Modern Equivalent Asset (MEA) and alternative site methods as appropriate. From 31 March 2018 PFI assets are valued excluding VAT.

Any uncertainty over the estimates and assumptions used for the valuation are mitigated by the use of professional valuers. They use industry standard indexation and rate figures provided by Building Cost Information Service (BCIS). Based on the valuation report, if there was a 5% positive or negative movement in the valuation of buildings, this would result in a movement of £2.5m in the value of assets.

Plant and equipment assets were last indexed using the latest available Consumer Price Indices (CPI), being for February 2024, as issued by the Office for National Statistics.

1.63 – Subsequent expenditure

Expenditure after items of property, plant and equipment have been put into operation, such as repairs and maintenance, is normally charged to the Statement of Comprehensive Income in the period in which it is incurred. In situations where it can be clearly demonstrated that the expenditure has resulted in an increase in the future economic benefits or service potential expected to be obtained from the use of an item of property, plant and equipment, and where the cost can be measured reliably, the expenditure is capitalised as an additional cost of that asset or as a replacement. The carrying amount of the part replaced is de-recognised.

1.64 – Depreciation

Items of property, plant and equipment are depreciated, using the straight line method, over their remaining useful economic lives in a manner consistent with the consumption of economic or service delivery benefits.

Freehold land is considered to have an indefinite life and is not depreciated.

Property, plant and equipment, which has been reclassified as ‘held for sale’ ceases to be depreciated upon reclassification. Assets in the course of construction and residual interests in off-Statement of Financial Position PFI contract assets are not depreciated until the asset is brought into use or reverts to the Trust, respectively.

The useful economic lives of property, plant and equipment are estimated by Leeds and York Partnership NHS Foundation Trust as follows:

Plant and machinery
  • Short life engineering plant and equipment – 5 years
  • Medium life engineering plant and equipment – 10 years
  • Long life engineering plant and equipment – 15 years
  • Short life medical and other equipment – 5 years
  • Medium life medical equipment – 10 years
  • Long life medical equipment – 15 years
Transport
  • Vehicles – 7 years
Furniture and fittings
  • Furniture – 10 years
Information technology
  • Office and IT equipment – 5 years
  • Mainframe type IT installations – 10 years

Buildings, installations and fittings are depreciated on their current value over the estimated remaining life of the asset as assessed by the Trust’s professional independent valuers. The assessed lives of the individual building elements may vary. Leaseholds are depreciated over the primary lease term.

Equipment is depreciated on current cost evenly over the estimated life of the asset.

The estimated useful life of an asset is the period over which the Trust expects to obtain economic benefits or service potential from it. This period is specific to the foundation trust and may be shorter than the physical life of the asset itself.

Assets held under finance leases (including leased land) are depreciated over the shorter of their estimated useful economic lives or the lease period. Where the Trust will, or is reasonably certain to, acquire ownership of the asset at the end of the lease, the asset is depreciated over its useful economic life.

Estimated useful lives and residual values are reviewed each year end, with the effects of any changes recognised on a prospective basis.

Where a large asset, for example a building, includes a number of components with significantly different asset lives, the components are treated as separate assets and depreciated over their own useful economic lives.

At the end of each reporting period, a transfer is made from the revaluation reserve to the income and expenditure reserve, in respect of the difference between the depreciation expense on the revalued asset and the depreciation expense based on the assets historic cost carrying value.

1.65 – Revaluation and Impairment

Increases in asset values arising from revaluations are taken to the revaluation reserve except where, and to the extent they, reverse an impairment for the same asset previously recognised in operating expenses. In this case they are recognised in operating income.

Impairments, that arise from a loss of economic benefit or service potential, are charged to operating expenses in the period that they occur. At the period end, a transfer is made from the revaluation reserve to the income and expenditure reserve for the amount of the impairment (or the remaining balance in the revaluation reserve relating to the asset if this is a lower amount).

Decreases in asset values and all other impairments are charged to the revaluation reserve to the extent that there is an available balance for the asset concerned, and thereafter, are charged to operating expenses.

Gains and losses recognised in the revaluation reserve are reported in the Statement of Comprehensive Income as an item of “other comprehensive income”.
At each reporting period end, the Trust checks whether there is any indication that any of its property, plant or equipment has suffered an impairment loss. If there is an indication of an impairment loss, the recoverable amount of the asset is estimated to determine whether there has been a loss and, if so, its amount.

1.66 – Non-current assets held for sale

Non-current assets are classified as held for sale if their carrying amount will be recovered principally through a sale transaction rather than through continuing use.
Assets intended for disposal are reclassified as ‘held for sale’ once all of the following criteria are met.

  • the asset is available for immediate sale in its present condition subject only to terms, which are usual and customary for such sales;
  • the sale must be highly probable, i.e. management are committed to a plan to sell the asset; an active programme has begun to find a buyer and complete the sale; the asset is being actively marketed at a reasonable price; the sale is expected to be completed within 12 months of the date of classification as ‘held for sale’; and the actions needed to complete the plan indicate it is unlikely that the plan will be dropped or significant changes made to it.

Following reclassification, the assets are measured at the lower of their existing carrying amount and their ‘fair value less costs to sell’. Fair value is open market value including alternative uses. Depreciation ceases to be charged and the assets are not revalued, except where the ‘fair value less costs to sell’ falls below the carrying amount.

Assets are de-recognised when all material sale contract conditions have been met. The non-current assets held for sale are identified in note 19.

The profit or loss arising on disposal of an asset is the difference between the sale proceeds and the carrying amount and is recognised in the Statement of Comprehensive Income. On disposal, the balance for the asset in the revaluation reserve is transferred to the income and expenditure reserve.

Property, plant and equipment, which is to be scrapped or demolished, does not qualify for recognition as ‘held for sale’ and instead is retained as an operational asset and the asset’s economic life is adjusted. The asset is de-recognised when scrapping or demolition occurs.

1.67 – Donated and grant funded assets

Donated and grant funded property, plant and equipment assets are capitalised at their fair value on receipt. The donation/grant is credited to income at the same time, unless the donor has imposed a condition that the future economic benefits embodied in the grant are to be consumed in a manner specified by the donor, in which case, the donation/grant is deferred within liabilities and is carried forward to future financial years to the extent that the condition has not yet been met.

The donated and grant funded assets are subsequently accounted for in the same manner as other items of property, plant and equipment.

1.7 – Private Finance Initiative (PFI) transactions

PFI transactions which meet the IFRIC 12 definition of a service concession, as interpreted in HM Treasury’s FReM, are accounted for as ‘on-Statement of Financial position’ by the Trust.

The underlying assets are recognised as property, plant and equipment at their fair value. An equivalent financial liability is recognised in accordance with HM Treasury’s FReM. Initial measurement of the asset and liability are in accordance with the initial measurement principles of IFRS 16 (see leases accounting policy).

The annual unitary payment is separated into the following component parts, using appropriate estimation techniques where necessary:
a)       Payment for the fair value of services received (including lifecycle costs);
b)       Payment for the PFI asset, comprising finance costs and the repayment of the liability; and
c)       Operating lease for the land.

a) Services received

The fair value of service received in the year is recorded under the relevant expenditure heading within operating expenses.

Leeds and York Partnership NHS Foundation Trust has adopted the approach that we incur the lifecycle costs evenly over the contract period as part of the unitary payment. This is due to the nature of the costs involved.

b) PFI assets and finance costs

Assets are subsequently accounted for as property, plant and equipment and/or intangible assets as appropriate.

The liability is subsequently reduced by the portion of the unitary charge allocated as payment for the asset and increased by the annual finance cost. The finance cost is calculated by applying the implicit interest rate to the opening liability and is charged to finance costs in the Statement of Comprehensive Income. The element of the unitary charge allocated as payment for the asset is split between payment of the finance cost and repayment of the net liability.

Where there are changes in future payments for the asset resulting from indexation of the unitary charge, the Trust remeasures the PFI liability by determining the revised payments for the remainder of the contract once the change in cash flows takes effect. The remeasurement adjustment is charged to finance costs in the Statement of Comprehensive Income.

c) Operating lease for the land

The land, which the PFI building is built on, is classified as an operating lease in accordance with HM Treasury’s FReM.

Assets contributed by the Trust to the operator for use in the scheme

Assets contributed for use in the scheme continue to be recognised as items of property, plant and equipment in the Trusts Statement of Financial Position.

Other assets contributed by the Trust to the operator

Assets contributed, e.g. cash payments and surplus property, by the Trust to the operator before the asset is brought into use, which are intended to defray the operator’s capital costs, are recognised initially as prepayments during the construction phase of the contract. Subsequently, when the asset is made available, the prepayment is treated as an initial payment towards the finance lease liability and is set against the carrying value of the liability.

Leeds and York Partnership NHS Foundation Trust did make an initial ‘bullet’ payment of cash upfront of £5.4m. This was off set against the initial liability (based on the fair value cost of the building less the £5.4m).

1.8 – Intangible Assets
1.81 – Recognition

Intangible assets are non-monetary assets without physical substance, which are capable of being sold separately from the rest of the Trust’s business or which arise from contractual or other legal rights. The Trust holds software licences as intangible assets. They are recognised only where it is probable that future economic benefits will flow to, or service potential be provided to, the Trust and where the cost of the asset can be measured reliably. Where internally generated assets are held for service potential, this involves a direct contribution to the delivery of services to the public.

Purchased computer software licences are capitalised as intangible non-current assets where expenditure of at least £5,000 is incurred. They are amortised over the shorter of the term of the licence and their useful economic lives, currently between 2 and 5 years depending on the software licence.

1.82 – Internally generated intangible assets

Internally generated goodwill, brands, mastheads, publishing titles, customer lists and similar items are not capitalised as intangible assets.

Expenditure on research is not capitalised.

Expenditure on development is capitalised only where all of the following can be demonstrated:

  • the project is technically feasible to the point of completion and will result in an internally generated intangible asset for sale or use;
  • the Trust intends to complete the asset and sell or use it;
  • the Trust has the ability to sell or use the asset;
  • how the intangible asset will generate probable future economic or service delivery benefits, e.g. the presence of a market for it or its output, or where it is to be used for internal use, the usefulness of the asset;
  • adequate financial, technical and other resources are available to the Trust to complete the development and sell or use the asset; and
  • the Trust can measure reliably the expenses attributable to the asset during development.
1.83 – Measurement

Intangible assets are recognised initially at cost, comprising all directly attributable costs needed to create, produce and prepare the asset to the point that it is capable of operating in the manner intended by management.

Subsequently intangible assets are measured at current value in existing use. Where no active market exists, intangible assets are valued at the lower of depreciated replacement cost and the value in use where the asset is income generating. Revaluations gains and losses and impairments are treated in the same manner as for property, plant and equipment, see notes 1.6.2 and 1.6.5.. An intangible asset which is surplus with no plan to bring it back into use is valued at fair value where there are no restrictions on sale at the reporting date and where they do not meet the definitions of investment properties or assets held for sale.

Intangible assets held for sale are measured at the lower of their carrying amount or fair value less costs to sell.

1.84 – Amortisation

Intangible assets are amortised on a straight line basis over their expected useful economic lives in a manner consistent with the consumption of economic or service delivery benefits. Amortisation is recognised in the Statement of Comprehensive Income.

1.9 – Inventories

Inventories are valued at the lower of cost and net realisable value, using the first in – first out cost formula. Inventories are identified in note 16. The Trust’s inventories do not include drugs, but comprise stationery, oil and other work stores.

1.10 – Cash and cash equivalents

Cash and cash equivalents comprise cash in hand, balances with banks and investments that mature in 3 months or less. Cash and bank balances are recorded at the current values of these balances in the Trust’s cash book. These balances exclude monies held in the Leeds and York Partnership NHS Foundation Trust’s bank account belonging to patients (see “third party assets” below). Interest earned on bank accounts is recorded as “interest receivable” in the period to which it relates. Bank charges are recorded as operating expenditure in the periods to which they relate.

1.11 – Provisions

Leeds and York Partnership NHS Foundation Trust provides for present legal or constructive obligations that are of uncertain timing or amount; for which it is probable that there will be a future outflow of cash or other resources; and a reliable estimate can be made of the amount. The amount recognised in the Statement of Financial Position is the best estimate of the resources required to settle the obligation. Where the effect of the time value of money is significant, the estimated risk-adjusted cash flows are discounted using HM Treasury’s discount rate in real terms. The discount rate for early retirement and injury benefit provisions (both use the HM Treasury’s pension discount rate) is 2.40% (2.45% in 2023/24) in real terms. The discount rate for other provisions varies depending on the timing of the liability from 4.03% (up to 5 years), 4.07% (5 – 10 years) and 4.81% over 10 years (in 2023/24 the discount rates were 4.26%, 4.03% and 4.72% respectively).

When some or all of the economic benefits required to settle a provision are expected to be recovered from a third party; the receivable is recorded as an asset, if it is virtually certain that reimbursement will be received and the amount of the receivable can be measured reliably.

Clinical negligence costs

From 1 April 2000, NHS Resolution took over full financial responsibility for all Existing Liabilities Scheme (ELS) cases unsettled at that date and from 1 April 2002 all Clinical Negligence Scheme for Trusts (CNST) cases. Provisions for these are included in the accounts of the NHS Resolution. Although the NHS Resolution is administratively responsible for all cases from 1 April 2000, the legal liability remains with Leeds and York Partnership NHS Foundation Trust.

NHS Resolution operates a risk pooling scheme under which the NHS Foundation Trust pays an annual contribution to the NHS Resolution, which, in return, settles all clinical negligence claims. Leeds and York Partnership NHS Foundation Trust does not include any amounts in its accounts relating to these cases. The total value of clinical negligence provisions carried by the NHS Resolution on behalf of the Trust is disclosed at note 25.

Non-clinical risk pooling

Leeds and York Partnership NHS Foundation Trust participates in the Property Expenses Scheme (PES) and the Liabilities to Third Parties Scheme (LTPS). Both are risk pooling schemes under which the Trust pays an annual contribution to the NHS Resolution and in return receives assistance with the costs of claims arising. The annual membership contributions, and any ‘excesses’ payable in respect of particular claims are charged to operating expenses when the liability arises; these are the only amounts included in the accounts of the Leeds and York Partnership NHS Foundation Trust.

1.12 – Contingencies

Contingent assets, i.e. assets arising from past events whose existence will only be confirmed by one or more future events not wholly within the entity’s control, are not recognised as assets, but are disclosed in note 26 where an inflow of economic benefits is probable.
Contingent liabilities are provided for where a transfer of economic benefits is possible. Otherwise, they are not recognised, but are disclosed in note 26 unless the probability of a transfer of economic benefits is remote. Contingent liabilities are defined as:

  • possible obligations arising from past events whose existence will be confirmed only by the occurrence of one or more uncertain future events not wholly within the entity’s control, or
  • present obligations arising from past events but for which it is not probable that a transfer of economic benefits will arise or for which the amount of the obligation cannot be measured with sufficient reliability.
1.13 – Value added tax (VAT)

Most of the activities of Leeds and York Partnership NHS Foundation Trust are outside the scope of VAT and, in general, output tax does not apply and input tax on purchases is not recoverable. Irrecoverable VAT is charged to the relevant expenditure category or included in the capitalised purchase cost of fixed assets. Where output tax is charged or input VAT is recoverable, the amounts are stated net of VAT.

1.14 – Corporation tax

Leeds and York Partnership NHS Foundation Trust is a Health Service Body within the meaning of s519A ICTA 1988 and accordingly is exempt from taxation in respect of income and capital gains within categories covered by this. There is a power for HM Treasury to disapply the exemption in relation to specified activities of a Foundation Trust (s519A (3) to (8) ICTA 1988). Accordingly, the Trust is potentially within the scope of corporation tax in respect of activities, which are not related to, or ancillary to, the provision of healthcare. Until the exemption is disapplied, the foundation trust has no corporation tax liability.

1.15 – Foreign exchange

The functional and presentational currency of the Leeds and York Partnership NHS Foundation Trust is sterling.

Transactions that are denominated in a foreign currency are converted into sterling at the exchange rate ruling on the date of each transaction. Gains and losses that result are taken to the Statement of Comprehensive Income.

1.16 – Third party assets

Assets belonging to third parties, in which the Leeds and York Partnership NHS Foundation Trust has no beneficial interest, (such as money held on behalf of patients) are not recognised in the accounts. However, they are disclosed in a separate note to the accounts, note 30, in accordance with the requirements of the HM Treasury FReM.

1.17 – Leases

A lease is a contract or part of a contract that conveys the right to use an asset for a period of time in exchange for consideration. An adaptation of the relevant accounting standard by HM Treasury for the public sector means that for NHS bodies, this includes lease-like arrangements with other public sector entities that do not take the legal form of a contract. It also includes peppercorn leases where consideration paid is nil or nominal (significantly below market value) but in all other respects meet the definition of a lease. The Leeds and York Partnership NHS Foundation Trust does not apply lease accounting to new contracts for the use of intangible assets.

The Leeds and York Partnership NHS Foundation Trust determines the term of the lease term with reference to the non-cancellable period and any options to extend or terminate the lease which the Trust is reasonably certain to exercise.

The Trust as lessee
Initial recognition and measurement

At the commencement date of the lease, being when the asset is made available for use, Leeds and York Partnership NHS Foundation Trust recognises a right of use asset and a lease liability.

The right of use asset is recognised at cost comprising the lease liability, any lease payments made before or at commencement, any direct costs incurred by the lessee, less any cash lease incentives received. It also includes any estimate of costs to be incurred restoring the site or underlying asset on completion of the lease term.

The lease liability is initially measured at the present value of future lease payments discounted at the interest rate implicit in the lease. Lease payments includes fixed lease payments, variable lease payments dependent on an index or rate and amounts payable under residual value guarantees. It also includes amounts payable for purchase options and termination penalties where these options are reasonably certain to be exercised.

Where an implicit rate cannot be readily determined, the Trust’s incremental borrowing rate is applied. This rate is determined by HM Treasury annually for each calendar year. A nominal rate of 4.72% applied to new leases commencing in 2024 and 4.81% to new leases commencing in 2025.

Subsequent measurement

As required by a HM Treasury interpretation of the accounting standard for the public sector, Leeds and York Partnership NHS Foundation Trust employs a revaluation model for subsequent measurement of right of use assets, unless the cost model is considered to be an appropriate proxy for current value in existing use or fair value, in line with the accounting policy for owned assets. Where consideration exchanged is identified as significantly below market value, the cost model is not considered to be an appropriate proxy for the value of the right of use asset.

Leeds and York Partnership NHS Foundation Trust subsequently measures the lease liability by increasing the carrying amount for interest arising which is also charged to expenditure as a finance cost and reducing the carrying amount for lease payments made. The liability is also remeasured for changes in assessments impacting the lease term, lease modifications or to reflect actual changes in lease payments. Such remeasurements are also reflected in the cost of the right of use asset. Where there is a change in the lease term or option to purchase the underlying asset, an updated discount rate is applied to the remaining lease payments.

Leases of land and buildings

Where a lease is for land and buildings, the land component is separated from the building component and the classification for each is assessed separately. Leased land, in the PFI, is treated as an operating lease.

1.18 – Public dividend capital (PDC) and PDC dividend

Public dividend capital (PDC) is a type of public sector equity finance based on the excess of assets over liabilities at the time of establishment of the original NHS Trust. HM Treasury has determined that PDC is not a financial instrument within the meaning of IAS 32.

A charge, reflecting the cost of capital utilised by Leeds and York Partnership NHS Foundation Trust, is paid over as PDC dividend. The charge is calculated at the rate set by HM Treasury (currently 3.5%) on the average relevant net assets of the Trust. Relevant net assets are calculated as the value of all assets less the value of all liabilities, except for donated assets and the average daily balance of cash held with the Government Banking Service, the National Loans Fund and PDC receivable/payable. Average relevant net assets are calculated as a simple mean of opening and closing relevant net assets.

In accordance with the requirements laid down by the Secretary of State (as the issuer of PDC), the dividend for the year is calculated on the actual average relevant net assets as set out in the pre-audit version of the accounts. The dividend is not revised should any adjustment to net assets occur as a result of the audit of the accounts.

1.19 – Losses and special payments

Losses and special payments are items that Parliament would not have contemplated when it agreed funds for the Health Service or passed legislation. By their nature they are items that ideally should not arise. They are therefore subject to special control procedures compared with the generality of payments. They are divided into different categories, which govern the way each individual case is handled.

Losses and special payments are charged to the relevant functional headings in the Statement of Comprehensive Income on an accruals basis. Note 31 is compiled directly from the losses and special payments register which is prepared, as per the DHSC GAM, on an accruals basis (with the exception of provisions for future losses).

1.20 – Financial instruments and financial liabilities
Recognition

Financial assets and financial liabilities arise where Leeds and York Partnership NHS Foundation Trust is party to the contractual provisions of a financial instrument, and as a result has a legal right to receive or a legal obligation to pay cash or another financial instrument.

The GAM expands the definition of a contract to include legislation and regulations which give rise to arrangements that in all other respects would be a financial instrument and do not give rise to transactions classified as a tax by ONS.

This includes the purchase or sale of non-financial items (such as goods or services), which are entered into in accordance with Leeds and York Partnership NHS Foundation Trust’s normal purchase, sale or usage requirements and are recognised when, and to the extent which, performance occurs, i.e., when receipt or delivery of the goods or services is made.

Derecognition

All financial assets are de-recognised when the rights to receive cash flows from the assets have expired or Leeds and York Partnership NHS Foundation Trust has transferred substantially all of the risks and rewards of ownership.

Financial liabilities are de-recognised when the obligation is discharged, cancelled or expires.

Classification and Measurement

Financial assets are categorised as ‘loans and receivables’ and financial liabilities are classified as ‘other financial liabilities’.

Loans and receivables

Loans and receivables are non-derivative financial assets with fixed or determinable payments, which are not quoted in an active market, and are included in current assets.

Leeds and York Partnership NHS Foundation Trust’s loans and receivables comprise: current investments, cash at bank and in hand, NHS receivables and other receivables.

Loans and receivables are recognised initially at fair value, net of transaction costs, and are measured subsequently at amortised cost, using the effective interest method. The effective interest rate is the rate that discounts exactly, the estimated future cash receipts through the expected life of the financial asset or, when appropriate, a shorter period, to the net carrying amount of the financial asset.

Other financial liabilities

Other financial liabilities are recognised initially at fair value, net of transaction costs incurred, and measured subsequently at amortised cost using the effective interest method. The effective interest rate is the rate that discounts exactly, the estimated future cash payments through the expected life of the financial liability or, when appropriate, a shorter period, to the net carrying amount of the financial liability. They are included in current liabilities except for amounts payable more than 12 months after the Statement of Financial Position date, which are classified as long-term liabilities. Interest on financial liabilities carried at amortised cost is calculated using the effective interest method and charged to finance costs. Interest on financial liabilities taken out to finance property, plant and equipment or intangible assets is not capitalised as part of the cost of those assets.

Impairment of financial assets

At the Statement of Financial Position date, Leeds and York Partnership NHS Foundation Trust assesses whether any financial assets, other than those held at ‘fair value through income and expenditure’ are impaired. Financial assets are impaired and impairment losses are recognised if, and only if, there is objective evidence of impairment as a result of one or more events which occurred after the initial recognition of the asset and which has an impact on the estimated future cash flows of the asset.

For financial assets carried at amortised cost, the amount of the impairment loss is measured as the difference between the asset’s carrying amount and the present value of the revised future cash flows discounted at the asset’s original effective interest rate. The loss is recognised in the income and expenditure account and the carrying amount of the asset is reduced through the use of a bad debt provision.

1.21 – Accounting standards that have been issued but have not yet been adopted
a) IASB standard and IFRIC interpretations

Under paragraph 30 of IAS 8, entities need to disclose any new IFRSs that are issued but not yet effective and that are likely to impact the entity.

b) Government Financial Reporting Manual (FReM) changes

In preparing the DH GAM, the Department of Health and Social Care must take account of the requirements of the Government FReM issued by HM Treasury. In some cases, where there is a compelling reason, HM Treasury may grant permission not to adopt a change to the FReM in the DH GAM.

c) Other changes

From 2013/14 the exemption applicable to NHS FTs from consolidating NHS charitable funds that they control has been removed. The effect on Leeds and York Partnership NHS Foundation Trust is the need to consider whether charitable fund income, expenditure, assets, liabilities and reserves should be consolidated within the Trusts main accounts. Income and expenditure between the Trust and the charitable fund would be eliminated on consolidation. Further details are included in note 1.25 – Charitable Funds.

d) IFRS 17 Insurance Contracts

The Standard is effective for accounting periods beginning on or after 1 January 2023. IFRS 17 has been adopted by the FReM from 1 April 2025. Adoption of the Standard for NHS bodies will therefore be in 2025/26. The Standard revises the accounting for insurance contracts for the issuers of insurance. Application of this standard from 2025/26 is not expected to have a material impact on the financial statements.

e) IFRS 18 Presentation and Disclosure in Financial Statements

IFRS 18 was issued in April 2024 and applies to periods beginning on or after 1 January 2027. The standard has not yet been adopted by FRAB for inclusion within the FREM and therefore it is not yet possible to confirm how this will impact on our accounts in the future.

f) IFRS 19 Subsidiaries without Public Accountability: Disclosures

IFRS 19 is effective for accounting periods beginning on or after 1 January 2027. The Standard is not yet UK endorsed and not yet adopted by the FReM. Early adoption is not permitted. The expected impact of applying the standard in future periods has not yet been assessed.

g) Changes to non-investment asset valuation

Following a thematic review of non-current asset valuations for financial reporting in the public sector, HM Treasury has made a number of changes to valuation frequency, valuation methodology and classification which are effective in the public sector from 1 April 2025 with a 5 year transition period. NHS bodies are adopting these changes to an alternative timeline.
Changes to subsequent measurement of intangible assets and PPE classification / terminology to be implemented for NHS bodies from 1 April 2025:

  • Withdrawal of the revaluation model for intangible assets. Carrying values of existing intangible assets measured under a previous revaluation will be taken forward as deemed historic cost.
  • Removal of the distinction between specialised and non-specialised assets held for their service potential. Assets will be classified according to whether they are held for their operational capacity.

Changes to valuation cycles and methodology to be implemented for NHS bodies in later periods:

  • A mandated quinquennial revaluation frequency (or rolling programme) supplemented by annual indexation in the intervening years.
  • Removal of the alternative site assumption for buildings valued at depreciated replacement cost on a modern equivalent asset basis. The approach for land has not yet been finalised by HM Treasury.

The impact of applying these changes in future periods has not yet been assessed. PPE and right of use assets currently subject to revaluation have a total book value of £50.6m as at 31 March 2025. Assets valued on an alternative site basis have a total book value of £35.6m at 31 March 2025.

1.22 – Accounting standards issued that have been adopted early by Leeds and York Partnership NHS Foundation Trust

No new accounting standards or revisions to existing standards have been early adopted in 2024/25

1.23 – Critical accounting judgements and key sources of estimation uncertainty

In the application of the Trust’s accounting policies, management is required to make judgements, estimates and assumptions about the carrying amounts of assets and liabilities that are not readily apparent from other sources. These estimates and associated assumptions are based on historical experience and other factors that are considered to be relevant. Actual results may differ from those estimates as the estimates and underlying assumptions are continually reviewed. Revisions to accounting estimates are recognised in the period in which the estimate is revised.

1.24 – Private patient income cap

Previously, NHS Foundation Trusts were required to disclose private patient income where this exceeded the amount specified. This disclosure is no longer required.

1.25 – Charitable funds

Under IAS 27 (revised) Leeds and York Partnership NHS Foundation Trust is required to consolidate any Charitable Funds that meet the definition of a subsidiary contained in the standard. HM Treasury has previously granted dispensation to NHS FT organisations in this respect, however this dispensation ended in 2013/14. Leeds and York Partnership NHS Foundation Trust has therefore considered the need to consolidate Leeds and York Partnership NHS Foundation Trust Charitable Fund within the main Trust accounts and concluded, although the Trust continues to meet the criteria within the accounting standard, the value of the Charitable Fund is not material and will not therefore be consolidated within the Trusts main accounts.

IAS 27 (revised) also requires specific disclosures to be included in the accounts. The dispensation previously granted did not include the requirement for appropriate disclosure and consequently note 33 – Charitable funds, continues to be included in the Trusts accounts in compliance with these disclosure requirements.

1.26 – Transfer of services

Where the Trust transfers a function to, or receives a function from another entity within the Whole of Government Accounts boundary this represents a “machinery of government change” regardless of the mechanism used to effect the combination, e.g., statutory merger or purchase of the business.

The Trust will normally account for a machinery of government change as a transfer by absorption. This includes all transfers of functions involving other bodies within the Department of Health and Social care’s Resource Accounting Boundary and transfers of functions involving local government bodies.

2 – Operating segments

Leeds and York Partnership NHS Foundation Trust (LYPFT) provides mental health and learning disability services across the city of Leeds. Specialist services including Forensics, Eating Disorders and CYPHMS are commissioned through Provider Collaboratives. Other specialist services such as Liaison, Gender and Perinatal are commissioned by NHS England and provided by LYPFT in Leeds, York and North Yorkshire.

The majority of Trust income (by value) is on a block basis. The Trust contracted with the West Yorkshire ICB for 58% of its income. The Trust also had contracts with NHS England and Local Authorities for the provision of clinical services and education training services.

Two operating segments are reported below. The operating segments are care services and hosted services. The hosted services segment includes the Commercial Procurement Collaborative (CPC), Research & Development, and the Northern School of Child & Adolescent Psychotherapy. The figures have been calculated using full absorption costing.
The reportable segments are those used by the Trust’s Board and management (the ‘Chief Operating Decision Maker’ as defined in IFRS 8, Operating Segments) to run the business. Segment information is presented on the same basis as that used for internal reporting purposes. The surplus or deficit for each segment is used to inform the Board of Directors on performance and to assist in negotiations with commissioners on the cost and resources needed to maintain services at a level consistent with the need of the population.

Further detail of each directorate can be found in the Annual Report of the Trust.

Care Services (Year ended 31 March)

2025

  • Income from activities: £249,808,000
  • Other operating income: £11,955,000
  • Total income: £261,763,000
  • Total expenditure: £261,804,000
  • Operating surplus: -£41,000
  • Non-operating income and expenditure: £3,386,000
  • Surplus/(Deficit) from continuing operations: £3,345,000

2024

  • Income from activities: £226,803,000
  • Other operating income: £15,407,000
  • Total income: £242,210,000
  • Total expenditure: £244,157,000
  • Operating surplus: -£1,947,000
  • Non-operating income and expenditure: £1,213,000
  • Surplus/(Deficit) from continuing operations: -£734,000
Hosted Services (Year ended 31 March)

2025

  • Other operating income: £15,668,000
  • Total income: £15,668,000
  • Total expenditure: £14,652,000
  • Operating surplus: £1,016,000
  • Non-operating income and expenditure: -£5,000
  • Surplus/(Deficit) from continuing operations: £1,011,000

2024

  • Other operating income: £14,692,000
  • Total income: £14,692,000
  • Total expenditure: £14,415,000
  • Operating surplus: £277,000
  • Non-operating income and expenditure: -£1,000
  • Surplus/(Deficit) from continuing operations: £276,000
Total (Year ended 31 March)

2025

  • Income from activities: £249,808,000
  • Other operating income: £27,623,000
  • Total income: £277,431,000
  • Total expenditure: £276,456,000
  • Operating surplus: £975,000
  • Non-operating income and expenditure: £3,381,000
  • Surplus/(Deficit) from continuing operations: £4,356,000

2024

  • Income from activities: £226,803,000
  • Other operating income: £30,099,000
  • Total income: £256,902,000
  • Total expenditure: £258,572,000
  • Operating surplus: -£1,670,000
  • Non-operating income and expenditure: £1,212,000
  • Surplus/(Deficit) from continuing operations: -£458,000

a) Income includes £257m (£228m in 2023/24) from NHS organisations (primarily £160m from the West Yorkshire ICB and £56m from NHS England).
b) Expenditure includes employee expenses £201,861k (£181,517k in 2023/24), premises £8,107k (£7,010k in 2023/24), depreciation and amortisation £7,657k (£6,929k in 2023/24) and establishment £2,280k (£2,963k in 2023/24).

3 – Revenue from patient care activities(Year ended 31 March)
2025
  • Integrated Care Boards and NHS England: £206,487,000
  • Foundation Trusts: £27,148,000
  • Local Authorities: £1,051,000
  • NHS other: £2,853,000
  • Non-NHS:
    • Income for social care clients: £9,761,000
    • Other: £2,508,000
  • Total revenue from patient care activities: £249,808,000
2024
  • Integrated Care Boards and NHS England: £189,970,000
  • Foundation Trusts: £25,306,000
  • Local Authorities: £109,000
  • NHS other: £2,192,000
  • Non-NHS:
    • Income for social care clients: £9,072,000
    • Other: £154,000
  • Total revenue from patient care activities: £226,803,000

All income from patient care activities is classed as commissioner requested services (CRS).

4 – Other operating revenue (Year ended 31 March)
2025
  • Research and development: £1,394,000
  • Education and training: £7,460,000
  • Non-patient care services to other bodies: £1,609,000
  • Contributions to expenditure donated from DHSC bodies for COVID: £0
  • Other income:
    • Inter NHS Foundation Trust: £597,000
    • Inter NHS Trust: £561,000
    • Inter RAB: £8,340,000
    • Inter Other WGA bodies: £1,584,000
    • Other (outside WGA): £5,126,000
  • Income in respect of staff costs where accounted on gross basis: £952,000
  • Total other operating revenue: £27,623,000
2024
  • Research and development: £1,744,000
  • Education and training: £6,689,000
  • Non-patient care services to other bodies: £1,429,000
  • Contributions to expenditure donated from DHSC bodies for COVID: £51,000
  • Other income:
    • Inter NHS Foundation Trust: £1,202,000
    • Inter NHS Trust: £485,000
    • Inter RAB: £6,780,000
    • Inter Other WGA bodies: £1,261,000
    • Other (outside WGA): £9,471,000
  • Income in respect of staff costs where accounted on gross basis: £987,000
  • Total other operating revenue: £30,099,000
4 – Other operating revenue (Year ended 31 March)
2025
  • Purchase of healthcare from NHS and DHSC bodies: £45,000
  • Purchase of healthcare from non-NHS and non-DHSC bodies: £18,602,000
  • MH collaboratives (NHS): £1,199,000
  • MH collaboratives (non-NHS): £7,383,000
  • Purchase of social care: £567,000
  • Staff and executive directors costs: £201,861,000
  • Non-executive directors: £238,000
  • Supplies and services – clinical (excluding drugs): £1,133,000
  • Supplies and services – clinical (COVID): £0
  • Supplies and services – general: £1,120,000
  • Drugs costs: £2,433,000
  • Consultancy: £0
  • Establishment: £2,280,000
  • Premises – business rates: £1,187,000
  • Premises – other: £6,614,000
  • Transport – business travel: £866,000
  • Transport – other: £834,000
  • Depreciation: £7,107,000
  • Amortisation: £550,000
  • Impairments net of (reversals): £419,000
  • Increase in impairment of receivables: £11,000
  • Provisions arising / (released): £733,000
  • Change in provisions discount rate: £3,000
  • Audit services – statutory audit: £192,000
  • Internal audit – non-staff: £113,000
  • Clinical negligence – NHS Resolution: £771,000
  • Legal fees: £306,000
  • Insurance: £232,000
  • Research and development: £1,588,000
  • Education and training: £1,550,000
  • Education and training (apprenticeship fund): £607,000
  • Lease expenditure – short term: £39,000
  • Lease expenditure – low value assets: £137,000
  • Early retirements: £6,000
  • Redundancy costs: £59,000
  • PFI scheme charges: £9,777,000
  • Car parking and security: £282,000
  • Other losses and special payments: £14,000
  • Other: £5,643,000
  • Total operating expenditure: £276,456,000
2024
  • Purchase of healthcare from NHS and DHSC bodies: £0
  • Purchase of healthcare from non-NHS and non-DHSC bodies: £21,225,000
  • MH collaboratives (NHS): £583,000
  • MH collaboratives (non-NHS): £6,871,000
  • Purchase of social care: £648,000
  • Staff and executive directors costs: £181,517,000
  • Non-executive directors: £237,000
  • Supplies and services – clinical (excluding drugs): £1,240,000
  • Supplies and services – clinical (COVID): £51,000
  • Supplies and services – general: £2,730,000
  • Drugs costs: £2,225,000
  • Consultancy: £34,000
  • Establishment: £2,963,000
  • Premises – business rates: £1,031,000
  • Premises – other: £7,507,000
  • Transport – business travel: £867,000
  • Transport – other: £939,000
  • Depreciation: £6,637,000
  • Amortisation: £292,000
  • Impairments net of (reversals): £2,535,000
  • Increase in impairment of receivables: £0
  • Provisions arising / (released): -£2,073,000
  • Change in provisions discount rate: -£45,000
  • Audit services – statutory audit: £122,000
  • Internal audit – non-staff: £107,000
  • Clinical negligence – NHS Resolution: £636,000
  • Legal fees: £214,000
  • Insurance: £227,000
  • Research and development: £1,908,000
  • Education and training: £1,614,000
  • Education and training (apprenticeship fund): £335,000
  • Lease expenditure – short term: £23,000
  • Lease expenditure – low value assets: £41,000
  • Early retirements: £9,000
  • Redundancy costs: £8,000
  • PFI scheme charges: £9,017,000
  • Car parking and security: £379,000
  • Other losses and special payments: £78,000
  • Other: £5,795,000
  • Total operating expenditure: £258,572,000

Details of provisions arising in year are included in note 25.
Details of the Directors’ remuneration can be found in Section 2.2 of the annual report.

MH Collaboratives – This is for West Yorkshire activity we pay for in other hospitals as a lead provider of Childrens MH services and adult eating disorders. The expenditure is split between activity in NHS and non-NHS hospitals

5.1 – Auditors remuneration

The Board of Governors appointed KPMG as external auditors of the Foundation Trust for 2024/25. The statutory audit fee will be £160k for 2024/25 excluding value added tax. This was the fee for an audit in accordance with the Audit Code issued by NHSi as updated in December 2014.

Financial Audit (Year ended 31 March)

2025

  • Financial audit: £160,000
  • Total: £160,000

2024

  • Financial audit: £102,000
  • Total: £102,000
6 – Operating leases
6.1 – As lessee

The leases are for buildings, vehicles and other equipment. Building leases include non specialised properties used for clinical purposes. Vehicle leases are for cars supplied to qualifying staff under a vehicle lease scheme. Other equipment leases are mainly for photocopy equipment in the various Trust properties.

Payments Recognised as an Expense (Year ended 31 March)

2025

  • Minimum lease payments: £232,000

2024

  • Minimum lease payments: £127,000
Total Future Minimum Lease Payments (Year ended 31 March)

2025

  • Not later than one year: £96,000
  • Between one and five years: £85,000
  • After five years: £2,000
  • Total: £183,000

2024

  • Not later than one year: £65,000
  • Between one and five years: £45,000
  • After five years: £0
  • Total: £110,000
7 – Employee costs and numbers
7.1 – Employee costs (Year ended 31 March)
2025
  • Salaries and wages:
    • Total: £148,400,000
    • Permanently employed: £128,861,000
    • Other: £19,539,000
  • Social security costs: £14,581,000
  • Employer contributions to NHS pension scheme: £18,053,000
  • Employer contributions to NHS pension scheme paid by NHSE: £11,871,000
  • Apprentice Levy: £709,000
  • Agency staff: £8,424,000
  • Employee benefits expense:
    • Total: £202,038,000
    • Permanently employed: £174,075,000
    • Other: £27,963,000
  • Of which:
    • Charged to capital: -£38,000
    • Recharged to income: -£139,000
  • Total employee costs: £201,861,000
2024
  • Salaries and wages:
    • Total: £133,162,000
    • Permanently employed: £115,894,000
    • Other: £17,268,000
  • Social security costs: £13,572,000
  • Employer contributions to NHS pension scheme: £16,306,000
  • Employer contributions to NHS pension scheme paid by NHSE: £7,121,000
  • Apprentice Levy: £662,000
  • Agency staff: £11,240,000
  • Employee benefits expense:
    • Total: £182,063,000
    • Permanently employed: £153,555,000
    • Other: £28,508,000
  • Of which:
    • Charged to capital: -£158,000
    • Recharged to income: -£388,000
  • Total employee costs: £181,517,000

There were no employee benefits paid in the year ended 2024/25 (£nil in 2023/24).

Full details of the Directors’ remuneration can be found in section 2.2 of the Annual Report, of which a summarised version is given below.

The disclosures required under the Hutton report can also be found in section 2.2 of the Annual Report.

Directors’ Remuneration (Year ended 31 March)

2025

  • Aggregate emoluments to Executive Directors: £925,000
  • Remuneration of Non-Executive Directors: £238,000
  • Pension cost: £88,000
  • Additional pension contribution from NHS England: £38,000
  • Total: £1,289,000

2024

  • Aggregate emoluments to Executive Directors: £868,000
  • Remuneration of Non-Executive Directors: £237,000
  • Pension cost: £82,000
  • Additional pension contribution from NHS England: £36,000
  • Total: £1,223,000

Remuneration of Non-Executive Directors include MH Act Managers £79k (£80k in 2023/24).

7.2 – Monthly average number of people employed (wte) (Year Ended 31 March)
2025
  • Medical and dental:
    • Total: 254
    • Permanently employed: 234
    • Other: 20
  • Administration and estates:
    • Total: 813
    • Permanently employed: 792
    • Other: 21
  • Healthcare assistants and other support staff:
    • Total: 1,021
    • Permanently employed: 721
    • Other: 300
  • Nursing, midwifery and health visiting staff:
    • Total: 884
    • Permanently employed: 822
    • Other: 62
  • Scientific, therapeutic and technical staff:
    • Total: 469
    • Permanently employed: 465
    • Other: 4
  • Social care staff:
    • Total: 50
    • Permanently employed: 50
    • Other: 0
  • Total staff (all categories):
    • Total: 3,491
    • Permanently employed: 3,084
    • Other: 407
2024
  • Medical and dental:
    • Total: 237
    • Permanently employed: 211
    • Other: 26
  • Administration and estates:
    • Total: 796
    • Permanently employed: 764
    • Other: 32
  • Healthcare assistants and other support staff:
    • Total: 1,020
    • Permanently employed: 708
    • Other: 312
  • Nursing, midwifery and health visiting staff:
    • Total: 839
    • Permanently employed: 781
    • Other: 58
  • Scientific, therapeutic and technical staff:
    • Total: 425
    • Permanently employed: 421
    • Other: 4
  • Social care staff:
    • Total: 43
    • Permanently employed: 43
    • Other: 0
  • Total staff (all categories):
    • Total: 3,360
    • Permanently employed: 2,928
    • Other: 432
8 – Retirements due to ill-health

During 2024/25 there were 7 (1 in 2023/24) early retirements from the Trust agreed on the grounds of ill-health. The estimated additional pension liability of these ill-health retirements will be £359k (£33k in 2023/24). The cost of these ill-health retirements will be borne by the NHS Business Services Authority – Pensions Division.

9 – Better Payment Practice Code (Year Ended 31 March)
Non-NHS Trade Invoices

2025

  • Total invoices paid: 16,500
  • Total value: £131,232,000
  • Invoices paid within target: 14,492
  • Value paid within target: £126,103,000
  • Percentage paid within target:
    • By number: 88%
    • By value: 96%

2024

  • Total invoices paid: 21,468
  • Total value: £131,202,000
  • Invoices paid within target: 19,877
  • Value paid within target: £126,978,000
  • Percentage paid within target:
    • By number: 93%
    • By value: 97%
NHS Trade Invoices

2025

  • Total invoices paid: 704
  • Total value: £15,134,000
  • Invoices paid within target: 660
  • Value paid within target: £14,208,000
  • Percentage paid within target:
    • By number: 94%
    • By value: 94%

2024

  • Total invoices paid: 627
  • Total value: £13,245,000
  • Invoices paid within target: 567
  • Value paid within target: £11,820,000
  • Percentage paid within target:
    • By number: 90%
    • By value: 89%

The Better Payment Practice Code requires the Trust to aim to pay all undisputed invoices by the due date or within 30 days of receipt of goods or a valid invoice, whichever is later.

10 – Finance Income (Year ended 31 March)
2025
  • Bank accounts: £6,034,000
  • Total finance income: £6,034,000
  • Includes accrued interest of £491,000
2024
  • Bank accounts: £6,414,000
  • Total finance income: £6,414,000
  • Includes accrued interest of £562,000
11 – Other gains and losses (Year ended 31 March)
2025
  • Gain on disposal of property, plant and equipment: £3,000
  • Loss on disposal of intangible assets: -£1,000
  • Total: £2,000
2024
  • Loss on disposal of property, plant and equipment: -£5,000
  • Total: -£5,000
12 – Finance costs (Year ended 31 March)
2025
  • Interest on obligations under finance leases: £169,000
  • Interest on obligations under PFI contracts:
    • Main finance cost: £1,580,000
    • Remeasurement of PFI liability due to change in index: £787,000
  • Total finance costs: £2,536,000
2024
  • Interest on obligations under finance leases: £168,000
  • Interest on obligations under PFI contracts:
    • Main finance cost: £1,978,000
    • Remeasurement of PFI liability due to change in index: £3,030,000
  • Total finance costs: £5,176,000
13 – Intangible assets
Computer Software – Purchased

2024/25

  • Gross valuation at 1 April 2024: £1,514,000
  • Additions purchased: £1,185,000
  • Disposals other than by sale: -£490,000
  • Revaluation/indexation: £68,000
  • Gross valuation at 31 March 2025: £2,277,000
  • Accumulated amortisation at 1 April 2024: £479,000
  • Disposals other than by sale: -£489,000
  • Charged during the year: £550,000
  • Accumulated amortisation at 31 March 2025: £540,000
  • Net book value at 31 March 2025: £1,737,000

2023/24

  • Gross valuation at 1 April 2023: £815,000
  • Additions purchased: £717,000
  • Disposals other than by sale: -£20,000
  • Revaluation/indexation: £2,000
  • Gross valuation at 31 March 2024: £1,514,000
  • Accumulated amortisation at 1 April 2023: £249,000
  • Disposals other than by sale: -£20,000
  • Revaluation: -£42,000
  • Charged during the year: £292,000
  • Accumulated amortisation at 31 March 2024: £479,000
  • Net book value at 31 March 2024: £1,035,000

Purchased computer software licences are capitalised as intangible fixed assets where expenditure of at least £5k is incurred. They are amortised over the shorter of the term of the licence and their useful economic lives, currently between 2 and 5 years depending on the software licence. The remaining economic life is assessed each year.

Quotations were sought in 2024/25 for the software licences and this led to an impairment charge to operating expenses of £0k (impairment charge of £0k in 2023/24).

14 – Property, plant and equipment – Detailed Summary (2024/25)
Cost or Valuation Movements
  • Opening balance at 1 April 2024: £80,600,000
  • Additions purchased:
    • Buildings: £10,489,000
    • Plant and machinery: £445,000
    • Information technology: £436,000
    • Furniture and fittings: £58,000
    • Total purchased additions: £11,428,000
  • Additions leased:
    • Buildings: £712,000
    • Information technology: £131,000
    • Total leased additions: £843,000
  • Additions leased at peppercorn rent:
    • Buildings: £24,000
  • Reclassifications:
    • £2,727,000 reclassified from assets under construction to buildings
  • Disposals:
    • Buildings: -£439,000
    • Plant and machinery: -£88,000
    • Transport equipment: -£183,000
    • Information technology: -£7,000
    • Furniture and fittings: -£281,000
    • Total disposals: -£998,000
  • Revaluation/indexation (losses)/gains:
    • Land: £1,000
    • Buildings: -£2,847,000
    • Plant and machinery: £63,000
    • Furniture and fittings: £12,000
    • Total revaluation impact: -£2,771,000
  • Dilapidation provisions capitalised in RoU asset:
    • Buildings: £175,000
  • Impairments:
    • Land: -£13,000
    • Buildings: -£252,000
  • Reversal of impairments:
    • Plant and machinery: £1,000
  • Closing balance at 31 March 2025: £89,037,000
Accumulated Depreciation Movements
  • Opening balance at 1 April 2024: £14,341,000
  • Disposals:
    • Buildings: -£398,000
    • Plant and machinery: -£88,000
    • Transport equipment: -£179,000
    • Information technology: -£7,000
    • Furniture and fittings: -£281,000
    • Total disposals: -£953,000
  • Revaluation/indexation (losses)/gains:
    • Buildings: -£4,151,000
    • Furniture and fittings: £8,000
    • Net revaluation impact: -£4,143,000
  • Impairments:
    • Buildings: £848,000
  • Reversal of impairments:
    • Buildings: -£428,000
  • Depreciation charged during the year:
    • ROU assets: £952,000
    • Peppercorn assets: £111,000
    • Standard depreciation:
      • Buildings: £3,836,000
      • Plant and machinery: £22,000
      • Transport equipment: £93,000
      • Information technology: £1,953,000
      • Furniture and fittings: £183,000
      • Total standard depreciation: £6,087,000
  • Closing accumulated depreciation at 31 March 2025: £16,815,000
Net Book Value at 31 March 2025
  • Land: £2,171,000
  • Buildings (excluding dwellings): £54,410,000
  • Assets under construction: £9,043,000
  • Plant and machinery: £497,000
  • Transport equipment: £559,000
  • Information technology: £4,562,000
  • Furniture and fittings: £980,000
  • Total net book value: £72,222,000
Asset Financing Breakdown
  • Owned assets: £62,266,000
  • PFI-financed assets: £4,860,000
  • Finance lease assets: £5,091,000
  • Donated assets: £5,000
  • Total: £72,222,000

The latest revaluation of land and buildings was carried out by the Valuation Office with an effective date of 31 March 2025.

Specialist land and buildings in operational use are valued at Depreciated Replacement Cost (DRC), using a Modern Equivalent Asset basis (MEA). The MEA basis includes consideration of modern building techniques, occupancy rates, service delivery output and alternative site as required.

Non specialist land and buildings in operational use are valued at open market value, assuming existing use.

The Foundation Trust’s property, plant and equipment are held for service delivery, rather than for cash generating purposes. Consequently, in accordance with the DH GAM, the “value in use” is assumed to be at least equal to the cost of replacing the service potential provided by the asset unless there has been a reduction in service potential. When measuring impairments, the recoverable amount for operational properties is considered to be the value in use rather than the “fair value less costs to sell”.

Dilapidation provisions arising are those included in the value of a lease asset under IFRS 16 Leases.

There are no restrictions imposed on the use of donated assets.

14 – Property, Plant and Equipment – Detailed Summary (2023/24)
Cost or Valuation Movements
  • Opening balance at 1 April 2023: £81,147,000
  • Additions purchased:
    • Buildings: £3,913,000
    • Information technology: £899,000
    • Furniture and fittings: -£30,000
    • Total purchased additions: £4,782,000
  • Additions leased:
    • Buildings: £142,000
    • Information technology: £147,000
    • Total leased additions: £289,000
  • Reclassifications:
    • Buildings: £4,223,000
    • Assets under construction: -£5,833,000
    • Information technology: £1,568,000
    • Furniture and fittings: £42,000
  • Disposals:
    • Plant and machinery: -£10,000
    • Transport equipment: -£126,000
    • Furniture and fittings: -£6,000
    • Total disposals: -£142,000
  • Revaluation/indexation (losses)/gains:
    • Land: £253,000
    • Buildings: -£5,653,000
    • Plant and machinery: £77,000
    • Furniture and fittings: -£22,000
    • Other adjustments: -£7,000
    • Total revaluation impact: -£5,352,000
  • Remeasurements of lease ROU liability:
    • Buildings: £290,000
    • Information technology: £18,000
    • Total: £308,000
  • Dilapidation provisions capitalised in RoU asset:
    • Buildings: £20,000
  • Impairments:
    • Buildings: -£445,000
    • Furniture and fittings: -£7,000
    • Total impairments: -£452,000
  • Closing balance at 31 March 2024: £80,600,000
Accumulated Depreciation Movements
  • Opening balance at 1 April 2023: £11,533,000
  • Disposals:
    • Plant and machinery: -£10,000
    • Transport equipment: -£112,000
    • Furniture and fittings: -£4,000
    • Total disposals: -£126,000
  • Revaluation/indexation (losses)/gains:
    • Buildings: -£6,288,000
    • Plant and machinery: £74,000
    • Furniture and fittings: -£14,000
    • Other adjustments: -£3,000
    • Total revaluation impact: -£6,231,000
  • Impairments:
    • Buildings: £2,533,000
  • Reversal of impairments:
    • Buildings: -£5,000
  • Depreciation charged during the year:
    • ROU assets: £977,000
    • Peppercorn assets: £111,000
    • Standard depreciation:
      • Buildings: £3,823,000
      • Plant and machinery: £37,000
      • Transport equipment: £98,000
      • Information technology: £1,410,000
      • Furniture and fittings: £181,000
      • Total standard depreciation: £5,549,000
  • Closing accumulated depreciation at 31 March 2024: £14,341,000
Net Book Value at 31 March 2024
  • Land: £2,183,000
  • Buildings (excluding dwellings): £54,894,000
  • Assets under construction: £1,281,000
  • Plant and machinery: £54,000
  • Transport equipment: £663,000
  • Information technology: £6,079,000
  • Furniture and fittings: £1,105,000
  • Total net book value: £66,259,000
Asset Financing Breakdown
  • Owned assets: £55,243,000
  • PFI-financed assets: £5,897,000
  • Finance lease assets: £5,112,000
  • Donated assets: £7,000
  • Total: £66,259,000
14.2 – Classification of impairments for Parliamentary budgeting purposes
Impairments and Reversals (Year ended 31 March)

2025

  • Changes in market place: £848,000
  • Reversals of impairments: -£429,000
  • Net impairment at 31 March 2025: £419,000

2024

  • Changes in market place: £2,540,000
  • Reversals of impairments: -£5,000
  • Net impairment at 31 March 2024: £2,535,000
15 – Capital commitments at 31 March
2025
  • Property, plant and equipment: £5,692,000
  • Total: £5,692,000
2024
  • No contracted capital commitments reported

These are for the Perinatal scheme at The Mount (£1,309k) and the High Intensity Rehabilitation Unit at Parkside Lodge (£4,383k).

16 – Inventories (Year ended 31 March)
2025
  • Energy, consumables and work in progress: £65,000
  • Total inventories: £65,000
  • Of which held at net realisable value: £65,000
2024
  • Energy, consumables and work in progress: £64,000
  • Total inventories: £64,000
  • Of which held at net realisable value: £64,000
16.1 – Inventories recognised in expenses (Year ended 31 March)
2025
  • Inventories recognised as an expense: £64,000
  • Total: £64,000
2024
  • Inventories recognised as an expense: £39,000
  • Total: £39,000
17 – Trade and other receivables (Year ended 31 March)
Current Receivables

2025

  • Contract receivables: £4,072,000
  • Accrued income: £4,839,000
  • Allowance for impaired contract receivables: -£443,000
  • Prepayments: £3,529,000
  • Interest receivable: £491,000
  • PDC receivable: £75,000
  • VAT: £816,000
  • Other receivables: £7,000
  • Total current receivables: £13,386,000

2024

  • Contract receivables: £5,173,000
  • Accrued income: £2,691,000
  • Allowance for impaired contract receivables: -£432,000
  • Prepayments: £3,159,000
  • Interest receivable: £562,000
  • PDC receivable: £90,000
  • VAT: £837,000
  • Other receivables: £7,000
  • Total current receivables: £12,087,000
Non-Current Receivables

2025

  • Prepayments: £8,318,000
  • Other receivables: £228,000
  • Total non-current receivables: £8,546,000

2024

  • Prepayments: £7,669,000
  • Other receivables: £221,000
  • Total non-current receivables: £7,890,000

The majority of trade is with Integrated Commissioning Boards (ICBs), as commissioners for NHS patient care services. As ICBs are funded by Government to buy NHS patient care services, no credit scoring of them is considered necessary.

Credit scoring is not applied to other receivables

17.1 – Receivables past their due date but not impaired (Year ended 31 March)
2025
  • By up to three months: £40,000
  • By three to six months: £0
  • Over six months: £0
  • Total: £40,000
2024
  • By up to three months: £950,000
  • By three to six months: £23,000
  • Over six months: £5,000
  • Total: £978,000

The Trust does not consider the above debtors, past their due date, to be impaired, based on previous trends and experience.

17.2 – Allowances for credit losses (Year ended 31 March)
2025
  • Balance at 1 April: £432,000
  • Increase in receivables impaired: £11,000
  • Balance at 31 March: £443,000
2024
  • Balance at 1 April: £432,000
  • Increase in receivables impaired: £0
  • Balance at 31 March: £432,000

The provision for impairment of receivables for the year ended 31 March 2025 has remained stable after taking all factors into consideration regarding the potential for recovery.

18 – Cash and cash equivalents (Year ended 31 March)
2025
  • Opening balance at 1 April: £116,678,000
  • Net change in year: £7,008,000
  • Closing balance at 31 March: £123,686,000
    • Cash with Government Banking Service: £123,533,000
    • Commercial banks and cash in hand: £153,000
  • As reported in:
    • Statement of financial position: £123,686,000
    • Statement of cash flows: £123,686,000
2024
  • Opening balance at 1 April: £122,374,000
  • Net change in year: -£5,696,000
  • Closing balance at 31 March: £116,678,000
    • Cash with Government Banking Service: £116,542,000
    • Commercial banks and cash in hand: £136,000
  • As reported in:
    • Statement of financial position: £116,678,000
    • Statement of cash flows: £116,678,000
19 – Non-current assets held for sale

At 31 March 2025 there are no assets held for sale (Nil in 2023/24).

20 – Trade and other payables (Year ended 31 March)
2025
  • Trade payables: £13,175,000
  • Non-NHS trade payables – capital: £8,421,000
  • Accruals: £19,764,000
  • Other payables: £5,979,000
  • Total: £47,339,000
2024
  • Trade payables: £13,360,000
  • Non-NHS trade payables – capital: £2,295,000
  • Accruals: £20,299,000
  • Other payables: £5,930,000
  • Total: £41,884,000
21 – Borrowings (Year ended 31 March)
Current Liabilities

2025

  • PFI liabilities: £6,612,000
  • Finance leases: £816,000
  • Total current borrowings: £7,428,000

2024

  • PFI liabilities: £5,888,000
  • Finance leases: £821,000
  • Total current borrowings: £6,709,000
Non-Current Liabilities

2025

  • PFI liabilities: £9,682,000
  • Finance leases: £4,216,000
  • Total non-current borrowings: £13,898,000

2024

  • PFI liabilities: £15,721,000
  • Finance leases: £4,326,000
  • Total non-current borrowings: £20,047,000
22 – Other liabilities (Year ended 31 March)
Current Liabilities
  • Deferred Income: £7,932,000 (as of 31 March 2025)
  • Deferred Income: £5,237,000 (as of 31 March 2024)
Total Current Liabilities
  • £7,932,000 (2025)
  • £5,237,000 (2024)
23 – Finance lease obligations (Year ended 31 March)
Undiscounted Future Lease Payments Payable
  • Not later than one year: £1,096,000 (2025), £999,000 (2024)
  • Later than one year and not later than five years: £3,073,000 (2025), £2,599,000 (2024)
  • Later than five years: £1,522,000 (2025), £2,352,000 (2024)
Total Gross Future Lease Payments
  • £5,691,000 (2025)
  • £5,950,000 (2024)
Finance Charges Allocated to Future Periods
  • (£659,000) (2025)
  • (£803,000) (2024)
Net Finance Lease Liabilities at 31 March
  • £5,032,000 (2025)
  • £5,147,000 (2024)
23.1 – Reconciliation of the carrying value of lease liabilities (Year ended 31 March)
Carrying Value at 31 March 2024
  • £5,147,000 (2025)
  • £5,344,000 (2024)
Movements During the Year
  • Lease Additions / Remeasurements: £843,000 (2025), £597,000 (2024)
  • Interest Charge Arising in Year: £169,000 (2025), £169,000 (2024)
  • Lease Payments: (£1,082,000) (2025), (£963,000) (2024)
  • Termination of Leases: (£45,000) (2025), not applicable in 2024
Carrying Value at 31 March 2025
  • £5,032,000 (2025)
  • £5,147,000 (2024)
24 – Private Finance Initiative (PFI) contracts
PFI schemes on-Statement of Financial Position

The PFI contract is for the provision of seven mental health units, providing a comprehensive range of mental health services. The estimated capital value of the PFI scheme is £43,778k. The first unit opened in December 2001 and the last unit opened in February 2003. The contract end date is July 2028. The Trust has the right to purchase the units at market value at the end of the contract.

More detail is provided in the PFI accounting policy in note 1.7.

Minimum amounts payable under the contract:

Asset Financing Component

Gross Payments

  • Not later than one year: £7,683,000 (2025), £7,413,000 (2024)
  • Later than one year and not later than five years: £10,243,000 (2025), £17,296,000 (2024)
  • Subtotal: £17,926,000 (2025), £24,709,000 (2024)
  • Less: Finance Cost Attributable to Future Periods: (£1,632,000) (2025), (£3,099,000) (2024)
  • Total Gross Payments: £16,294,000 (2025), £21,610,000 (2024)

Present Value of Payments

  • Not later than one year: £7,396,000 (2025), £7,136,000 (2024)
  • Later than one year and not later than five years: £9,082,000 (2025), £14,814,000 (2024)
  • Subtotal: £16,478,000 (2025), £21,950,000 (2024)
  • Less: Finance Cost Attributable to Future Periods: (£184,000) (2025), (£340,000) (2024)
  • Total Present Value of Payments: £16,294,000 (2025), £21,610,000 (2024)
Services Component

Gross Payments

  • Not later than one year: £8,636,000 (2025), £8,332,000 (2024)
  • Later than one year and not later than five years: £11,515,000 (2025), £19,442,000 (2024)
  • Later than five years: not applicable
  • Total: £20,151,000 (2025), £27,774,000 (2024)

The future services amounts due as at 31 March 2025 reflect an adjustment for the RPI indexation of the unitary payment applied during 2024/25.

The amount charged to operating expenses during the year in respect of services was £8,344k (2023/24 £7,597k).

24.1 – Analysis of amounts payable to service concession operator
Gross Payments (Unitary Payment)
  • £18,109,000 (2025)
  • £17,570,000 (2024)
Consisting of:
  • Interest Charge: £1,580,000 (2025), £1,978,000 (2024)
  • Repayment of Finance Lease Liability: £6,102,000 (2025), £5,435,000 (2024)
  • Service Element and Other Charges to Operating Expenses: £8,875,000 (2025), £8,160,000 (2024)
  • Revenue Lifecycle Maintenance: £902,000 (2025), £857,000 (2024)
  • Addition to Lifecycle Prepayment: £650,000 (2025), £1,140,000 (2024)
  • Capital Lifecycle Maintenance: not applicable
Total
  • £18,109,000 (2025)
  • £17,570,000 (2024)

The addition to lifecycle prepayment relates to a rent free period at the end of the contract £650k (£1,140k 2023/24). Service element and other charges to operating expenses includes the operating lease payments for the land element of the properties £530k (£481k 2023/24).

25 – Provisions (Year ended 31 March)
2025

Current Provisions

  • Pensions Relating to Other Staff: £163,000
  • Legal Claims: £394,000
  • Redundancy: £654,000
  • Other: £1,860,000
  • Total Current Provisions: £3,071,000

Non-Current Provisions

  • Pensions Relating to Other Staff: £1,073,000
  • Other: £3,771,000
  • Total Non-Current Provisions: £4,844,000
2024

Current Provisions

  • Pensions Relating to Other Staff: £156,000
  • Legal Claims: £38,000
  • Redundancy: not applicable
  • Other: £1,908,000
  • Total Current Provisions: £2,102,000

Non-Current Provisions

  • Pensions Relating to Other Staff: £1,045,000
  • Other: £5,519,000
  • Total Non-Current Provisions: £6,564,000
Year Ended 31 March 2024
  • Opening Balance (1 April 2023):
    • Pensions: £1,218,000
    • Legal Claims: £175,000
    • Redundancy: £2,182,000
    • Other: £8,890,000
    • Total: £12,465,000
  • Movements During the Year:
    • Arising:
      • Pensions: £161,000
      • Legal Claims: £57,000
      • Other: £53,000
    • Change in Discount Rate:
      • Pensions: (£45,000)
      • Other: (£49,000)
    • Used:
      • Pensions: (£154,000)
      • Legal Claims: (£14,000)
      • Other: (£1,515,000)
    • Reversed Unused:
      • Legal Claims: (£21,000)
      • Redundancy: (£2,182,000)
      • Other: (£126,000)
    • Unwinding of Discount:
      • Pensions: £21,000
      • Other: £15,000
  • Closing Balance (31 March 2024):
    • Pensions: £1,201,000
    • Legal Claims: £197,000
    • Redundancy: £0
    • Other: £7,268,000
    • Total: £8,666,000
Year Ended 31 March 2025
  • Opening Balance (1 April 2024):
    • Pensions: £1,201,000
    • Legal Claims: £197,000
    • Redundancy: £0
    • Other: £7,268,000
    • Total: £8,666,000
  • Movements During the Year:
    • Arising:
      • Pensions: £180,000
      • Legal Claims: £360,000
      • Redundancy: £654,000
      • Other: £280,000
    • Change in Discount Rate:
      • Pensions: £3,000
    • Used:
      • Pensions: (£163,000)
      • Legal Claims: (£155,000)
      • Other: (£1,380,000)
    • Reversed Unused:
      • Pensions: (£14,000)
      • Legal Claims: (£8,000)
      • Other: (£537,000)
    • Unwinding of Discount:
      • Pensions: £29,000
  • Closing Balance (31 March 2025):
    • Pensions: £1,236,000
    • Legal Claims: £394,000
    • Redundancy: £654,000
    • Other: £5,631,000
    • Total: £7,915,000
Expected Timing of Cash Flows (as at 31 March 2025)
  • Between 1 April 2025 and 31 March 2026:
    • Pensions: £163,000
    • Legal Claims: £394,000
    • Redundancy: £654,000
    • Other: £1,860,000
    • Total: £3,071,000
  • Between 1 April 2026 and 31 March 2030:
    • Pensions: £653,000
    • Other: £3,423,000
    • Total: £4,076,000
  • Thereafter:
    • Pensions: £420,000
    • Other: £348,000
    • Total: £768,000
  • Grand Total: £7,915,000

The pensions provision is in respect of employees who have taken early retirement through injury or prior to 1995. These provisions are calculated using current year payments and GAD tables as issued by the Office for National Statistics. The GAD tables provide an estimate of remaining lives, which the provision is based on. Payments made against the pensions provisions are quarterly to the NHS Business Services Authority Pensions Division. Due to the nature of the other provisions, there is no certainty regarding the timing of payments.

The legal claims provision is in respect of excess payments to NHS Resolution for employers’ and public liability claims. NHS Resolution provides estimates of the likely outcome of the case and damages/costs to be paid. The provision is calculated based on these estimates. It also includes legal costs for an employee tribunal £353k (£158k 2023/24).

Other provisions comprise the commitment placed on the Trust in ensuring it meets its obligations in respect of dilapidation costs £460k (£393k 2023/24), IT software contracted out services vat £194k (£258k 2023/24), Pension Annual Allowance (as per national guidance) £235k (£228k 2023/24) and onerous contracts in relation to two of the Trust’s PFI assets £4,546k (£6,370k 2023/24).

The unwinding of discount on the provisions appears as a finance cost on the face of the Statement of Comprehensive Income.

Leeds and York Partnership NHS Foundation Trust has no expected reimbursements for any class of provision made.

£6,640k is included in the provisions of the NHS Resolution at 31 March 2025 in respect of the clinical negligence liabilities of the Trust (31 March 2024 £7,089k).

26 – Contingent liabilities
Year Ended 31 March 2025
  • Other: £22,000
  • Total Contingent Liabilities: £22,000
Year Ended 31 March 2024
  • Other: £22,000
  • Total Contingent Liabilities: £22,000

Contingent liabilities represent excess payments not provided for on legal cases being dealt with by NHS Resolution, on the Trust’s behalf, (primarily in respect of employer’s liability – £22k in 2024/25 and £22k in 2023/24). Due to the nature of the amounts and timing of the cash flows it would be impractical to estimate the value and timings of the amounts and cash flows.

27 – Financial Instruments

Leeds and York Partnership NHS Foundation Trust’s financial assets are classified either as “loans and receivables” financial assets. All the Trust’s financial liabilities are classified as “other liabilities”.

Leeds and York Partnership NHS Foundation Trust undertakes active financial risk management to manage its exposure to risk, particularly credit risk and treasury risk. Similar to general risk management, financial risk management requires identifying its sources, measuring it and implementing plans to address them.

27.1 – Financial assets – carrying amount
Year Ended 31 March 2025
  • Receivables: £8,959,000
  • Cash at Bank and in Hand: £123,686,000
  • Total Financial Assets: £132,645,000
Year Ended 31 March 2024
  • Receivables: £7,994,000
  • Cash at Bank and in Hand: £116,678,000
  • Total Financial Assets: £124,672,000
Ageing of Overdue Receivables (as at 31 March 2025)
  • 1–30 days: £32,000
  • 31–60 days: £8,000
  • 61–90 days: £0
  • 91–180 days: £0
  • Greater than 180 days: £0
  • Total Overdue Receivables: £40,000
27.2 – Financial liabilities – carrying amount
Year Ended 31 March 2025
  • Payables: £40,952,000
  • PFI and Finance Lease Obligations: £21,326,000
  • Provisions Under Contract: £7,721,000
  • Total Financial Liabilities: £69,999,000
Year Ended 31 March 2024
  • Payables: £35,196,000
  • PFI and Finance Lease Obligations: £26,756,000
  • Provisions Under Contract: £8,408,000
  • Total Financial Liabilities: £70,360,000
27.3 – Fair values of loans and receivables and other financial liabilities

The fair value of current loans and receivables are considered to be equal to their carrying amounts. There are no non-current loans and receivables.

The fair values of current financial liabilities are considered to be equal to their carrying amounts.

27.4 – Financial risk management

IFRS 7 requires disclosure of the role that financial instruments have had during the year in creating or changing the risks a body faces in undertaking its activities. Leeds and York Partnership NHS Foundation Trust’s activities are incurred primarily under annual service agreements with local Commissioning Groups, which are financed from resources voted annually by Parliament. Consequently the Trust’s financial risks are relatively small in comparison with commercial entities. The Trust does not use financial instruments to alter or hedge its risk and therefore their importance to the Trust’s finances are similarly relatively low.

Credit risk

This is the risk that other parties may not pay amounts that are due from them to Leeds and York Partnership NHS Foundation Trust. The majority of the Trust’s income comes from contracts with other public sector bodies, however, and therefore the Trust has low exposure to credit risk. The maximum exposures as at 31 March 2025 are in receivables from customers, as disclosed in the Trade and other receivables note.

Leeds and York Partnership NHS Foundation Trust’s treasury management operations are carried out by the finance department, within parameters defined formally within the Trust’s Standing Financial Instructions and policies agreed by the Board of Directors. The Trust mitigates the risks surrounding treasury management by investing in low risk banks/government backed investors. Trust treasury activity is subject to review by the Trust’s internal auditors.

Liquidity risk

Leeds and York Partnership NHS Foundation Trust’s net operating costs are incurred primarily under annual service agreements with local Commissioning Groups, which are financed from resources voted annually by Parliament. Leeds and York Partnership NHS Foundation Trust also largely finances its capital expenditure from funds generated through operating surpluses. Consequently, the Trust is not considered to be exposed to significant liquidity risks (the inability of paying financial liabilities).

Leeds and York Partnership NHS Foundation Trust’s main long term liability is its PFI obligation, with the contract ending in 2028. Further information on the commitments under this contract are provided in note 24.

Market risk

Market risk comprises three elements: foreign currency risk, interest rate risk and price risk.

Foreign currency risk

This is the risk that Leeds and York Partnership NHS Foundation Trust’s income and expenditure could be affected materially by foreign exchange gains and losses on foreign currency transactions. However the Trust has no foreign currency income and negligible foreign currency expenditure. Consequently, exposure to currency risk is not significant.

Interest rate risk

This is the risk that Leeds and York Partnership NHS Foundation Trust’s income and expenditure could be materially affected by changes in interest rates on financial liabilities, e.g. borrowing and financial assets. However, a high percentage of the Trust’s financial assets and a high percentage of its financial liabilities carry nil or fixed rates of interest. Leeds and York Partnership NHS Foundation Trust is not, therefore, exposed to significant interest-rate risk.

Price risk

As explained in note 24, Leeds and York Partnership NHS Foundation Trusts’ annual unitary payment under its PFI scheme is subject to annual indexation in line with the RPIX. The Trust is therefore exposed to pricing risk in this regard. The annual adjustments are reflected in finance costs, operating expenses and property, plant and equipment additions respectively.

For 2024/25 the percentage increase in the unitary payment was 3.64%, equalling a monetary decrease of (£2,318k) (11.98%, £1,729k in 2023/24).

The table below shows a sensitivity analysis of the impact on cash payments and on the surplus/deficit for the year if the uplift had been between 3.7% and 5.5%.

2024/25 Uplift in unitary payment

Year Ended 31 March 2025

Actual Uplift at 3.64%

  • Recognised in Finance Costs: (£2,641,000)
  • Recognised in Operating Expenses: £323,000
  • Recognised in Surplus/Deficit: (£2,318,000)

Uplift at 3.7%

  • Recognised in Finance Costs: (£2,628,000)
  • Recognised in Operating Expenses: £328,000
  • Recognised in Surplus/Deficit: (£2,300,000)
  • Net Impact on Surplus/Deficit: (£18,000)

Uplift at 5.5%

  • Recognised in Finance Costs: (£2,243,000)
  • Recognised in Operating Expenses: £487,000
  • Recognised in Surplus/Deficit: (£1,756,000)
  • Net Impact on Surplus/Deficit: (£562,000)

Year Ended 31 March 2024

Actual Uplift at 11.98%

  • Recognised in Finance Costs: £781,000
  • Recognised in Operating Expenses: £948,000
  • Recognised in Surplus/Deficit: £1,729,000

Uplift at 3.7%

  • Recognised in Finance Costs: (£1,366,000)
  • Recognised in Operating Expenses: £293,000
  • Recognised in Surplus/Deficit: (£1,073,000)
  • Net Impact on Surplus/Deficit: £2,802,000

Uplift at 5.5%

  • Recognised in Finance Costs: (£899,000)
  • Recognised in Operating Expenses: £435,000
  • Recognised in Surplus/Deficit: (£464,000)
  • Net Impact on Surplus/Deficit: £2,193,000

Leeds and York Partnership NHS Foundation Trust is a public benefit corporation, which was established by the granting of authorisation by the independent Regulator for NHS Foundation Trusts, NHS Improvement.

Government Departments and their agencies are considered by HM Treasury as being related parties. During the year the Trust has had a significant number of material transactions with other NHS Bodies. In addition, the Trust has had a significant number of material transactions in the ordinary course of its business with other Government Departments and other central and local Government bodies.

The individuals and entities that the Department of Health and Social Care identifies as meeting the definition of Related Parties set out in IAS 24 (Related Party Transactions) are also deemed to be related parties of entities within the Departmental Group. The Trust had significant transactions with 1 of these bodies during 2024/25.
During the year 2024/25, Leeds and York Partnership NHS Foundation Trust had significant transactions with Leeds University, where 1 Non Executive Director of the Trust’s Board holds a position of employment with the university.

During the year Leeds and York Partnership NHS Foundation Trust had the following material transactions with entities, which are considered related parties:

Year Ended 31 March 2025
  • University of Leeds
    • Payments: £554,000
    • Receipts: £147,000
    • Amounts Due From: £57,000
  • Alzheimer’s Society
    • Payments: £416,000
Year Ended 31 March 2024
  • University of Leeds
    • Payments: £576,000
    • Receipts: £119,000
    • Amounts Owed To: £40,000
  • Alzheimer’s Society
    • Payments: £417,000
    • Amounts Due From: £142,000

In 2024/25, the Trust had £3k of related party transactions with its charitable fund (2023/24 £3k).

Year Ending 31 March 2026
  • West Yorkshire ICB: £159,393,000
  • NHS England: £34,099,000
  • Total Income from Related Parties: £193,492,000

These commitments are material transactions relating to NHS bodies. The figures are draft and relate to block contract values.

The Trust has no expenditure commitments with related parties for the year ending 31 March 2026.

2025

Income

  • Department of Health and Social Care: £761,000
  • Other DHSC Group Bodies: £244,345,000
  • Other: £12,777,000
  • Total Income: £257,883,000

Expenditure

  • Other DHSC Group Bodies: £14,953,000
  • Other: £45,804,000
  • Total Expenditure: £60,757,000
2024

Income

  • Department of Health and Social Care: £1,132,000
  • Other DHSC Group Bodies: £228,117,000
  • Other: £10,687,000
  • Total Income: £239,936,000

Expenditure

  • Other DHSC Group Bodies: £13,396,000
  • Other: £38,470,000
  • Total Expenditure: £51,866,000
2025

Receivables

  • Department of Health and Social Care: £4,000
  • Other DHSC Group Bodies: £5,562,000
  • Other: £821,000
  • Total Receivables: £6,387,000

Payables

  • Other DHSC Group Bodies: £5,320,000
  • Other: £6,016,000
  • Total Payables: £11,336,000
2024

Receivables

  • Department of Health and Social Care: £8,000
  • Other DHSC Group Bodies: £5,160,000
  • Other: £837,000
  • Total Receivables: £6,005,000

Payables

  • Other DHSC Group Bodies: £2,611,000
  • Other: £5,930,000
  • Total Payables: £8,541,000
29 – Intra-Government and other balances (Year ended 31 March)
2025

Current Receivables

  • Balances with Other Central Government Bodies: £820,000
  • Balances with Local Authorities: £5,000
  • Balances with NHS Bodies: £5,562,000
  • Total Intra-Government Receivables: £6,387,000
  • Balances with Bodies External to Government: £6,999,000
  • Total Current Receivables: £13,386,000

Non-Current Receivables

  • Balances with Bodies External to Government: £8,546,000

Current Payables

  • Balances with Other Central Government Bodies: £5,979,000
  • Balances with Local Authorities: £37,000
  • Balances with NHS Bodies: £5,192,000
  • Total Intra-Government Payables: £11,208,000
  • Balances with Bodies External to Government: £36,131,000
  • Total Current Payables: £47,339,000

Non-Current Payables

  • Not reported
2024

Current Receivables

  • Balances with Other Central Government Bodies: £837,000
  • Balances with NHS Bodies: £5,168,000
  • Total Intra-Government Receivables: £6,005,000
  • Balances with Bodies External to Government: £6,083,000
  • Total Current Receivables: £12,088,000

Non-Current Receivables

  • Balances with Bodies External to Government: £7,890,000

Current Payables

  • Balances with Other Central Government Bodies: £5,930,000
  • Balances with NHS Bodies: £2,611,000
  • Total Intra-Government Payables: £8,541,000
  • Balances with Bodies External to Government: £33,342,000
  • Total Current Payables: £41,883,000

Non-Current Payables

  • Not reported
30 – Third party assets

The Trust held £348k cash and cash equivalents at 31 March 2025 (£370k 2023/24), which relates to monies held on behalf of service users.

31 – Losses and special payments

There were 4 cases of losses totalling £0k (4 in 2023/24 totalling £48k) and 17 special payments totalling £13k (29 in 2023/24 totalling £30k) during the year. These amounts are reported on an accruals basis, excluding provisions for future losses.

Losses
  • Cash – Other:
    • Number: 4 (2)
    • Value: £0,000 (£0,000)
  • Bad Debts – Other:
    • Number: 0 (2)
    • Value: £0,000 (£48,000)
  • Total Losses:
    • Number: 4 (4)
    • Value: £0,000 (£48,000)
Special Payments
  • Ex-gratia – Loss of Personal Effects:
    • Number: 15 (20)
    • Value: £2,000 (£5,000)
  • Ex-gratia – Personal Injury with Advice:
    • Number: 2 (9)
    • Value: £11,000 (£25,000)
  • Total Special Payments:
    • Number: 17 (29)
    • Value: £13,000 (£30,000)

Figures in brackets relate to 2023/24.

32 – Events after the reporting period

There were no events after the reporting period that had an impact on the Trust’s 2024/25 accounts (2023/24: none).

33 – Leeds and York Partnership NHS Foundation Trust Charitable Fund (Year ended 31 March)
2025
  • Income: £5,000
  • Expenditure: (£15,000)
  • Net Movement in Funds: (£10,000)
  • Current Assets: £104,000
  • Current Liabilities: (£8,000)
  • Total Charitable Funds: £96,000
2024
  • Income: £6,000
  • Expenditure: (£7,000)
  • Net Movement in Funds: (£1,000)
  • Current Assets: £119,000
  • Current Liabilities: (£10,000)
  • Total Charitable Funds: £109,000

The Charitable fund is not consolidated within these accounts but is disclosed in line with IAS 27 (revised).
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Contact Information

Leeds and York Partnership NHS Foundation Trust

Trust Headquarters
St Mary’s House
St Mary’s Road
Potternewton
Leeds
LS7 3JX
Tel: 0113 85 55000
Website: Leeds and York Partnership NHS Foundation Trust

Chief Executive

If you have a comment for our Chief Executive, please contact:
Dr Sara Munro
Tel: 0113 85 55913
Email: Denise Campbell

Patient Advice and Liaison Services (PALS)

If you need any help or advice about our services, please contact:
PALS Team.
Tel: 0800 0525 790 (Freephone)
Email: Patient Advice and Liaison Services

Membership

If you are interested in becoming a member of Leeds and York Partnership NHS Foundation Trust, please contact:
The Membership Office
Tel: 07977327628
Email: The Membership Office
Web: Membership

Communications

If you have a media enquiry, require further information about our Trust or would like more copies of this report please contact:
The Communications Team
Tel: 0113 85 55989
Email: the Communications Team

Members of the Board of Directors and Council of Governors

Can be contacted by email at the addresses shown on our website at:

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Page last updated: 24th Jul 2025 1:30pm