DrPA Secure - 42 Kew Court

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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 7 quality statements from this key question. There were systems in place to identify and report safeguarding issues. Staff worked collaboratively with the wider healthcare services, support systems and partners to improve outcomes for patients.

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

The service had a positive culture towards safety. They listened to concerns about safety, investigating and reporting on safety events. Lessons were learnt to identify and share good practice within the service.

Leaders demonstrated they managed incidents and complaints appropriately and used learning to improve care for patients. All incidents and complaints were discussed in senior meetings, and remedial actions were monitored to ensure their completion. Staff also reviewed complaints and incidents to identify themes and take action to improve their service We saw an example of where a prescription error had been identified, and the actions taken across the service reduced the risk of such incidents being repeated.

There was a process to record and investigate complaints, and learning was shared across the organisation. There were processes for reporting and investigating significant events and incidents, including near misses and safety events. Staff understood how to raise concerns and report incidents. Key staff were trained for undertaking formal investigations if required. However, there were limited avenues to ensure staff read and understood learning or changes when shared service wide.

The service shared clear and accurate information with relevant professionals and partners when supporting decision-making and care delivery for patients.

The service worked with healthcare partners to establish and maintain safe systems of care, with appropriate oversight of care. Some partners shared safety concerns due to medicines-related errors including prescribing errors.

Staff showed a clear understanding of their responsibilities to ensure referrals were made in line with relevant policies and procedures. Multi-disciplinary meetings were held where patients with more complex needs or those approaching the end of life could be discussed, supporting coordinated person-centred care.

The service worked with partners when delays to external referrals were experienced through operational or security reasons to ensure patients remained safe.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

The service had systems to protect vulnerable people from abuse. The safeguarding lead was supported by a GP for clinical oversight, and there was evidence to show how this worked in practice.

The service worked with partners to protect people from harm and gave examples of where the service had discussed and raised concerns. There were effective systems for monitoring and managing safeguarding concerns or alerts.

Staff had received training in safeguarding adults and children relevant to their role, and they were able to access policies and procedures which contained up to date information and guidance. They were aware of who the safeguarding leads were for the service and how to raise concerns.

Processes were in place to ensure safe remote consultations. Patient risk was mitigated with another clinician present during calls, and if the connection was interrupted, there were fallback arrangements via a dedicated telephone line to a duty manager or the shared clinical system. On-site staff followed local emergency management procedures for patients who deteriorated or needed urgent medical assistance during the call.

Information governance arrangements were in place to keep records secure. Staff used laptops provided by the provider, and NHS Trust-issued encrypted laptops when viewing confidential patient information. They had appropriate systems in place to ensure a safe and secure connection.

The organisation had taken proactive steps to prepare for cyber‑security risks and was working towards a recognised accreditation. They confirmed they had not experienced any data breaches.

The provider supported staff safety in relation to lone working, workstation assessments and occupational health provision. Leaders gave examples where they had offered staff support after difficult or distressing situations, and they emphasised their commitment to being available for staff when needed.

During an interview, leaders could not explain how they assured themselves that the premises their staff were working in were safe. Which included fire safety, equipment checks, infection prevention and control, compliance or emergency arrangements. They told us staff would inform them of any concerns.

They acknowledged they would benefit from introducing a more structured approach to gaining assurance around environmental risks. They told us they would strengthen engagement processes with the host Trusts.

The provider demonstrated a range of systems that supported safe and effective staffing across their prison sites. Rotas were planned effectively using a web-based management system, with clear visibility across all locations. Leaders had a strong understanding of site‑specific needs and rotas were planned months ahead, using a pool of regular and ad‑hoc GP's. Colour‑coding, standard operating procedures, and oversight in structured meetings meant gaps were identified and addressed. Reconciliation processes were in place to check contractual obligations were met and to resolve any issues with under or over-delivery of shifts.

We found recruitment checks were carried out in accordance with regulations, including for agency staff and locums. The recruitment process was tracked on their management system, with clear on-boarding stages, appropriate checks, and a supportive induction. This included site visits, shadowing and buddying arrangements. Systems were in place to ensure there was an appropriate skill mix, and staff used flags to identify competencies or special interests to help match staff to the needs of each prison. We were given examples where the leaders had made responsible workforce decisions, only placing staff who were qualified and competent to work in a role.

There was a programme of learning and development for staff, including mandatory training modules. We saw training completion was monitored by service leads and senior managers, although we noted this could be improved to include routine monitoring of training on learning disabilities and autism, and sepsis or serious infections. The provider told us they would take immediate action to amend their online training and tracking system.

The provider used monthly newsletters to communicate updates and information on the latest guidance. They described collaborative working relationships and an open culture where staff could reach out for advice or support. They had several mechanisms for identifying performance concerns, including audits, contract reviews, and appraisals. However, the provider acknowledged that some aspects of clinical supervision and formal ongoing support needed refinement to ensure timely interventions.

We reviewed staff feedback and found GP's felt able to raise concerns and were confident leaders would take action. However, they felt communication could improve. Information we reviewed also indicated that some GP's felt isolated in their role and wanted more access to support and better engagement with peers. The provider was aware of this and planned to improve communication and engagement, using a bespoke GP portal and regular webinars. They were also considering forums to enhance reflective practice and strengthen clinical networks. Occupational health, well-being services and an employee assistance program were available

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

There were systems and processes to support patient care, respond to safety alerts and medicine recalls. The service worked collaboratively with partners, who completed joint and individual audits and reviews on prescribing. We saw evidence of prescribing reviews for patients on an antidepressant medicine inviting patients in for face to face meetings.

Staff worked within their scope of practice for prescribing and were supported and supervised by medical staff.

The approach to medicines reflected current and relevant best practice. Staff followed established processes to ensure that patients who were prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, although could not confirm that everyone had received an annual medicines review.

The service had undertaken a high-risk medicines audit in December 2025 and planned to carry them out every six months.

The service had several antimicrobial stewardship audits undertaken where the trust was recommended to send swabs for microscopy and culture testing, but no action had been taken to encourage staff to ensure this was completed.