CQC publishes report on perinatal mental health unit in Leeds

The Care Quality Commission (CQC) has published a report following an inspection of perinatal mental health service run by Leeds and York Partnership NHS Foundation Trust.

CQC carried out an unannounced inspection of the perinatal mental health service in Leeds in September last year. This is the first time the service has been inspected.

The unit provides a specialist service with an eight-bed ward for people in the late stages of pregnancy or have a child under one year old and are experiencing significant mental health challenges.

The service’s overall rating is good. How safe, effective, caring and responsive the service is, has also been rated good, and how well-led the service is rated requires improvement.

During the inspection, CQC found a breach of regulation in relation to good governance, this was regarding monitoring mandatory training. CQC asked the trust to submit an action plan showing what action it is taking in response to this. Inspectors also found the unit’s risk register wasn’t comprehensive and had only one set of risks identified.

Linda Hirst, CQC deputy director of operations in the north, said:

“We were pleased to find a safe, responsive and welcoming environment at Leeds and York Partnership NHS Trust’s mother and baby unit. Staff worked hard to create a relaxing atmosphere and foster caring relationships with people using the service which laid good foundations for their care and treatment.

“People told us they felt safe and that the good relationships they had with staff meant their care was very responsive to their individual needs. Staff involved people in creating their care and treatment plans helping people to have a level of control at what could be a distressing time in their life.

“People using the service and their partners could attend their own care reviews, and the unit also involved people in providing wider feedback in how the unit was run through a community meeting.

“Staff supported people to take part in activities that were important to them. It was great to see people had access to various therapies and activities, including occupational therapy, psychological therapies and assistance with daily living activities.

“Staff informed safeguarding teams about every person admitted to the unit and provided a summary on discharge, to ensure nobody slipped through the net without support. A specialist perinatal social worker also worked with the team one day a week and contributed to reviews when appropriate.

“However, we have told the trust that they need to ensure they’re monitoring staff’s completion of mandatory training, and ensuring they have the right legal certificates for the controlled drugs on the unit.

“Overall, Leeds and York Partnership NHS Trust should be pleased with the findings of this report, which highlights many areas of good practice and a positive environment for people needing help and support. We have identified areas that they need to address and will continue to monitor them to check their progress.”

Nichola Sanderson, Director of Nursing and Professions, Leeds and York Partnership NHS Foundation Trust, said:

“I’m incredibly proud of my colleagues in our perinatal mental health service. Their dedication to excellence reflects our vision to lead the way in mental health care, and their care and compassion has been recognised in their first CQC inspection.

I welcome the CQC’s findings, and I’m pleased that it highlights the safe and responsive care provided by our dedicated staff.

We acknowledge the areas for improvement and have a plan in place to address mandatory training compliance which has significantly improved since the inspection. Additionally, the service has a process to review its risk register regularly to ensure risks are detailed and actions in place to ensure ongoing quality and safety.

We remain committed to delivering high-quality care and will continue working closely with our colleagues, service users, and partners to build on the positive findings in this report.”

Inspectors also found:

• Staff supported people to maintain contact with their families, and there were no restrictions on visiting times.
• Leaders investigated incidents that were reported and shared lessons learned with the team and wider service, helping to keep people safe.
• People had a perinatal risk assessment as well as a safety plan if required on admission to the unit.
• Staff completed comprehensive assessments which included regular health checks.
• Staff respected the individual needs of people from different ethnic, cultural or religious backgrounds. The service provided easy read material and baby books in different languages, supporting accessibility for all people using the service.
• There was a positive team culture among staff. Their workloads were manageable and they felt safe on the wards. Staff retention was high and new starters had a structured induction when they joined.

The report has been published on the CQC website.

Page last updated: 3rd Mar 2025 11:49am