HMP Leicester

On this page

• 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 5 quality statements for this key question. We found the service had made sufficient progress to address the regulatory breaches found at our previous assessment. Processes for medicines had improved to help ensure timelessness for patients as well as appropriate storage. Complaints processes had been reviewed and examples we looked at were timely; person centred and addressed the issues raised.

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

At our last assessment, we found that patients’ complaints were not always processed appropriately or consistently responded to within the timeframes set out in the provider’s policy.

During this inspection, we found that the provider had strengthened its complaints process to ensure that all concerns and complaints were formally recorded, managed, and responded to appropriately. Comprehensive audits had been undertaken, which included actions such as further correspondence with complainants to ensure responses were thorough, addressed all issues raised, and were person-centred. Since the introduction of the revised process, all complaints had been responded to within the provider's established timescales.

At our last assessment we found that improvement actions arising from the analysis of incidents, risks, and meeting discussions were not consistently completed which limited the opportunity to minimise the risk of their recurrence.

During this assessment, we found that systems had been strengthened through a comprehensive review of all outstanding improvement actions and the implementation of a centralised action-tracking process. This process was accessible to all relevant staff and was regularly monitored and reviewed as part of the provider’s governance, management, and quality assurance arrangements.

We also found effective mechanisms in place to ensure that learning from incidents was shared across the service. This included the development and dissemination of alert notices, as well as discussion and reflection at team meetings, helping to promote continuous learning and service improvement.

At our previous assessment we found there was no structured approach to the delivery of long-term condition management, to ensure patients’ health was monitored, and to ensure their annual reviews were carried out.

During this assessment, we found that the provider had established a clinical pathway for people with long-term conditions, which commenced during the reception screening process. The provider had also implemented a process known as Early Days in Custody, whereby all new patients were discussed at a multidisciplinary team meeting and appropriate actions were identified and taken.

Patients identified as having a long-term condition were subsequently booked into a weekly clinic with an advanced clinical practitioner for assessment, ongoing review, and treatment where required.

The provider was not using a formal recall system for the ongoing management of long-term conditions. While we found no evidence of unmet need during this assessment and the majority of patients had relatively short stays at the establishment, there remained a risk that some patients requiring ongoing reviews of their needs and treatment could be missed without a formalised recall system in place.

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.

At our previous assessment we found that medical equipment had not always been monitored to ensure its safety and effectiveness. We found items within clinical rooms that had passed their expiry date.

During this assessment, we found that all medical equipment had undergone the required testing and that the equipment reviewed was within its expiry date. The provider had further strengthened its governance processes by introducing weekly oversight checks to ensure equipment continued to be appropriately monitored and maintained.

​ At our previous assessment we found gaps in staff supervision and training compliance.

At this assessment we found that compliance with mandatory training had improved.

Supervision compliance, in line with the provider's policy, had improved for both managerial and clinical supervision. However, the provider needed to strengthen the recording and documentation of supervision sessions to provide assurance that they were being undertaken consistently. The provider should also be assured that the format and content of sessions effectively meet the professional support and development needs of staff.

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

At our last assessment systems in place for the proper and safe management of medicines were not all implemented effectively. Patients were placed at risk because they experienced delays receiving their medicines. Prescribers were not always available or failed to respond promptly.

At this assessment, we found that processes had been strengthened to support timely access to medicines for patients. Improvements included increased access to prescribers, including during evening periods, as well as the introduction of a clinical advice line and an electronic prescribing system. The provider had also implemented a comprehensive audit process, which demonstrated that patients were receiving timely access to their prescribed medicines.

At our last assessment we found the cold chain was not always maintained to ensure safe and effective medicines.

During this assessment, we found that the pharmacy lead had delivered training to staff on the recording, monitoring and escalation of fridge and room temperature checks. A guidance document outlining the required processes had been developed and shared with all relevant staff. We found that daily temperature monitoring was being undertaken consistently and that appropriate action was taken when readings fell outside the required parameters.