HMP Onley

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• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed 2 quality statements for this key question. The provider had not made sufficient progress to address the regulatory breaches found at our previous assessment.

Staffing levels and deployment of staff had not improved, although a recruitment drive meant that additional staff were due to commence. There was improved oversight to book patients for review of their mental health medicines.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

The judgement for Safeguarding is based on the latest evidence we assessed for the Safe key question.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe environments is based on the latest evidence we assessed for the Safe key question.

The service was not staffed safely and staff were not deployed effectively to meet patient need.

At the last inspection we found that nursing staff were not deployed effectively and that nurses mainly triaged patients and attended ACCT reviews, with no therapeutic intervention offered. During this inspection we found there had been limited improvement and rotas showed the service was regularly understaffed. There was a 25% vacancy rate for mental health nursing staff and 100% vacancy rate for one health care assistant. Each week day shift was funded for 3 nurses and one health care assistant, but almost all shifts were covered by only 2 mental health nurses.

At the last inspection we found that there were insufficient staff within the therapy team. During this assessment we found that a recruitment drive had been successful for a 0.5 whole time equivalent (wte) psychologist due to start date in February 2026. An assistant psychologist post was also appointed to during the week of inspection; a start date was yet to be agreed. A locum psychologist provided 0.2 wte cover each week, which was not sufficient to meet patient need. An art therapist was in post. At the time of inspection 57 patients had been waiting up to 25 weeks for therapy.

The judgement for Infection prevention and control is based on the latest evidence we assessed for the Safe key question.

Accurate, up-to-date information about patients’ medicines was available and physical health checks were undertaken.

At the last inspection we found that there was no system in place to ensure oversight of patients' with mental health needs medicines reviews and physical health checks. During this inspection we found that staff had developed spreadsheets to provide better oversight, this served as a prompt to ensure patients were invited to their medicines and physical health check reviews.