Our quality and performance

Leeds and York Partnership NHS Foundation Trust provides services for the local population of Leeds and specialist services at a regional level. Some of these services have a national reputation.

Our Trust places great emphasis on the quality of our services and we seek to deliver high quality care that is effective, safe and meets the needs of our service users, providing a positive and supportive experience for those who use our services and their carers.

Our Trust is regulated by the Care Quality Commission (CQC) and has contractual requirements to report to NHS Improvement, NHS England and local commissioners on the performance and quality of our services against agreed measures. This information can be found in our Integrated Quality and Performance Report (IQPR) and more information on our IQPRs can be found below.

Our Performance and Quality Team monitor this performance framework across our Trust which enables target setting, monitoring and assurance and continuous improvement. In particular our Trust is directed by the five domains of the CQC in delivering a quality service, namely:

  1. Are services safe?
  2. Are services effective?
  3. Are services caring?
  4. Are services responsive?
  5. Are services well-led?

Our Trust is also currently developing a Quality Strategy which identifies key indicators that will further demonstrate the high quality services we offer. These indicators have been agreed through consultation with service users, carers and staff.

Our CQC ratings

In its latest report, the CQC said staff treated patients with compassion and kindness and they respected patients’ privacy and dignity – which was backed up by direct feedback from patients themselves. They also said staff involved families and carers and supported their ongoing care and recovery.

A team of CQC inspectors visited the Trust in July and August 2019 to assess seven of its services looking at whether services are safe, effective, caring, responsive and well-led. They inspected:

  1. acute wards for adults of working age and psychiatric intensive care units,
  2. forensic inpatient/secure wards,
  3. wards for older people with mental health problems,
  4. wards for people with learning disability or autism,
  5. long stay/rehabilitation mental health wards for working age adults,
  6. community-based mental health services for adults of working age, and
  7. community-based mental health services for older people.

Inspectors also looked specifically at the Trust’s management and leadership to check if it was well-led overall. The Trust’s overall ratings have improved from requires improvement to good, following the previous inspection in 2018 (see table below).

Safe Effective Caring Responsive Well-led Overall
Requires improvement Good

(up from requires improvement in 2018)

Good Good Good Good

View our full Trust and service ratings at a glance.

The full report, including ratings, is available at: https://www.cqc.org.uk/provider/RGD

Service Delivery and Performance Reports

High quality and meaningful information allows service users, carers and staff within our Trust to:

  • Make better informed and more meaningful decisions based on good evidence
  • Make accurate judgements on service quality and outcomes
  • Identify service delivery problems and develop strategies to fix these
  • Benchmark our services against other services and learn from this
  • Assure service users, the general public, commissioners and regulators that our Trust meets its statutory reporting requirements
  • Ensure transparency and openness.

We produce a regular Service Delivery and Performance report which measures the quality and performance of our Trust against a set of key measures known as ‘indicators’.

This report is produced every month and on the third month (March, June, September, December) a quarterly view is included covering the previous three months. This quarterly view includes additional information and an additional set of indicators for us to measure our quality and performance against.

The Service Delivery and Performance report is made up of national requirements and those that have been agreed with the commissioners of our services, as well as agreed local metrics that are important for monitoring our service delivery.

Monthly Service Delivery and Performance Reports

Infection Prevention and Control Reports

The Infection Prevention and Control Team works to ensure the Trust delivers care safely to prevent service users developing infection as a result of the healthcare they receive. The team works closely with colleagues within LYPFT and also partners across the health and social care landscape of Leeds and our region. Our aim is to promote a clean and safe environment for service users, visitors and staff who access our services.

The Infection Prevention and Control, Medical Devices and Antimicrobial Stewardship committee provide both strategic and operational leadership in relation to IPC standards and performance. You can download the Infection, Prevention, Control and Medical Devices Annual Report which summarises the work undertaken for the period 1 April 2022 to 31 March 2023.

The Trust has registered with the Care Quality Commission as having appropriate arrangements in place for the prevention and control of infections.

Quality Accounts

Service users want to know they are receiving the very best quality of care. All NHS foundation trusts must produce reports on the quality of care (as part of their annual reports). Quality accounts, also known as quality reports, help trusts to improve public accountability for the quality of care they provide.

Our annual quality reports incorporate all the requirements of quality accounts regulations as well as our additional reporting requirements.

Our Trust also obtains external assurance on our quality reports, subjecting each annual report to independent scrutiny to ensure we improve the quality of our data on which our performance reporting depends.

Read the 2022/23 Quality Report here

If you’d like to find out more about the Trust’s work over the past 12 months and what we have achieved, see our latest Annual Review and Annual Report.

The Annual Review is designed to be a lighter and easier to read version of our comprehensive accounts.

Previous years Quality Reports:

Read the 2017/18 Quality Report here.

Read the 2018/19 Quality Report here.

Read the 2019/20 Quality Report here.

Read the 2020/21 Quality Report here.

Read the 2021/22 Quality Report here


Our Safeguarding Team provide advice and support to staff on all child and adult safeguarding concerns. This can include telephone or in-person support and attendance at clinical meetings. We provide both formal and strategic links with social services, the police and other agencies in relation safeguarding matters and they take a lead for our Trust on multi-agency pathways for domestic abuse, Prevent, female genital mutilation (FGM), human trafficking and hate crime.

Visit our safeguarding page for more information

Safe staffing

Since May 2014, all hospitals are required to publish information about the number of registered nurses (RN) and health support workers (HSW) on duty per shift.

This initiative is part of the NHS response to the Francis Report which called for greater openness and transparency in the health service.

Full details of staffing levels are reported to public meetings of our Board of Directors and made accessible to external scrutiny via NHS UK. There is also a requirement to openly display information for patients and visitors in all of our wards that shows the planned and actual staffing available at the start of every shift.

Our Trust currently reports on 27 inpatient areas and in line with the above commitments the purpose of the unify reports and Board reports is to provide assurance that we are safely staffed in our most restrictive (inpatient) areas. Publishing monthly information about our staffing levels enables us to be transparent about where our staffing challenges are and put plans in place to make improvements.

However, we know that safer staffing is not just about numbers or nurses, and that other professional colleagues and partners support safe care on our wards.

We set up a Safer Staffing Steering Group in April 2018 with the purpose of ensuring robust processes are in place to monitor and review staffing levels, providing assurance that staffing levels are safe and appropriate.

We are continuously scrutinising available data and in conjunction with our local and national partners we are implementing the use of an evidence based safer staffing tool. The tool will enable our wards to gather a bank of data to predict ward activity , staffing levels required and prepare appropriately to provide better outcomes and experiences for our patients and staff.

Visit our Board meetings page to look at our Board papers including our safe staffing Board reports

Monthly Safe Staffing Reports

Reports from previous years

View the Safe Staffing Reports from 2023
View the Safe Staffing Reports from 2022
View the Safe Staffing Reports from 2021
View the Safe Staffing Reports from 2020
View the Safe Staffing Reports from 2019
View the Safe Staffing Reports from 2018
View the Safe Staffing Reports from 2017

View the Safe Staffing Reports from 2016
View the Safe Staffing Reports from 2015

NHS Staff Surveys

The NHS Staff Survey provides a regular opportunity for staff at LYPFT to say how they feel about working in the Trust. The survey is aligned to the NHS People Promise.

You can read the results of the annual Staff Survey for 2023 on our news page.


Inpatient and Community Survey

Every NHS service provider must run a service user survey each year. The survey is managed by an independent company which sends a questionnaire to a sample of representative service users and inpatients,  then works with the answers given to produce result  ‘scorecards’.  These scorecards  can then be compared with other Mental Health Trusts and Community Interest Companies which deliver mental health services.

Acute Inpatient Services

Download the full Mental Health inpatient survey, or alternatively you can download a summary of the report.

Community Mental Health

Download the full mental health community services report for 2021.


Mixed sex accommodation

Declaration of compliance

We are proud to confirm that mixed sex accommodation has been eliminated in all our in-patient facilities.

Every patient has the right to receive high quality care that is safe, effective and respects their privacy and dignity. Leeds and York Partnership Foundation NHS Trust is committed to providing every patient with same sex accommodation, because it helps to safeguard their privacy and dignity when they are often at their most vulnerable.

We are proud to confirm that mixed sex accommodation has been virtually eliminated in our organisation, with the majority of our facilities having single bedroom accommodation. Service users who are admitted to any of our hospitals will only share the room where they sleep with members of the same sex, and same sex toilets and bathrooms will be close to their bed area. Sharing with members of the opposite sex will only happen by exception based on clinical need (for example where patients need specialist equipment such as in our Learning Disabilities Respite Service for people with Complex Multiple Impairment).

The assessment of compliance has been based on the principles agreed by the Department of Health and includes the actions taken to achieve compliance, the assurance systems in place to monitor compliance, the management of breaches and the communications to patients and the public about privacy and dignity.

Read a full copy of our statement of compliance

Learning from Deaths Policy

This policy shows how we respond to deaths in our care, how we review them and how the Trust will learn from them.

The policy also sets out how our staff can support the involvement of families and carers when a death has occurred and make it easier to ask questions about the care they received.

Read our Learning From Deaths policy