DrPA Secure - Oakhill Secure Training Centre

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 looked at 8 quality statements in this key question.

We found concerns regarding healthcare and medicines management, including incomplete care records, missed healthcare interventions and poor documentation of risks. Medicines administration and stock control were inconsistent, with gaps in electronic records, delays in therapy, and inadequate emergency provisions. Mental health care was delayed, and key health information was not always obtained on admission. Positive improvements included robust safeguarding practices, good access to allied health professionals, good infection control practice, increased staffing, and the introduction of assistant psychologists, which enhanced care and outcomes. The provider took immediate action to address concerns raised during the inspection.

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

Since our last inspection the provider had worked hard to improve the practice and culture of safety incidents. All staff we spoke with fully understood the provider’s expectations regarding incidents and were able to clearly outline the actions required when incidents occurred.

Following each incident, leaders ensured all learning was captured and shared to improve care for children. For example, following one incident, managers had a debrief with the member of staff to reflect and improve their practice. A review of the incident was conducted and the findings shared with the wider staffing team to minimise the risk of recurrence.

During our inspection we saw a number of actions taken by leaders to improve practice within the service. Staff listened to the feedback and took steps to adapt and improve practice in order to better care for children.

Some children arriving at the STC did not receive mental health care in good time. For example, one child did not speak to a member of the mental health team for 18 days following admission. Referral systems to the mental health service were not in place. Staff we spoke with told us differing processes and care records did not capture the referral process.

When children arrived to the STC, key healthcare information was not always sought from community providers to inform care. For example, one child told care staff they had aparticular health condition. We saw no evidence of any action being taken to contact the previous care providers to better understand how the condition affected the child. This meant children were at risk of worsening health conditions.

The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We raised our concerns with the provider during the inspection who took action to address the concerns.

Children had good access to allied healthcare professionals such as dental care and physiotherapy. Waiting times were reasonable and the quality of care provided was good.

Where children required care in a community setting such as a hospital, the provider had an effective system in place. Plans were made in conjunction with operational staff to facilitate the community appointment.

Safeguarding practices were robust with staff demonstrating a sound understanding of their role and responsibility to keep children safe from harm. Policies were in place to guide staff when dealing with safeguarding concerns.

Staff had received training at an appropriate level and were supported to understand what it meant to keep children safe. We saw good examples of safeguarding practice during our inspection. For example, one child had made a disclosure to care staff. We saw the correct process was followed and steps were taken to safeguard the child.

Known risks to children were not always considered or reflected in care records. For example, one child’s care records did not clearly detail a known allergy. In addition, staff we spoke with did not know the details of the allergy or how it affected the child.

Where healthcare interventions were required to better manage children’s health, they were not always completed. For example, one child had a particular health condition that necessitated regular blood tests for ongoing monitoring of this condition. We found these blood tests were not always completed as required. In addition, care records did not fully outline the condition or its impact on the child. This meant children were at risk of harm.

Staff generally knew the children’s health needs well and were able to verbally demonstrate their role in supporting them. However, care records did not always clearly outline the risks to children or provide staff with sufficient guidance. For example, one child was known to experience seizures. Although some information had been shared with operational staff, there was no clear document in place to outline the clinical care of the child’s needs.

Where risks to children changed, records were not always updated to reflect the change. For example, one child developed new behaviours which could lead to harm. Although action was taken to support the child, care records were not updated to reflect the new risk or guide staff.

The provider’s ‘my story’ document included good information regarding children’s history, preferences and future goals. However, clinical care records did not always demonstrate children were involved in their care planning and their views were not always sought.

For example, too many children did not have care plans in place. Another child with mental health needs had no information included in their care records detailing what support they wished to receive or what their goals were. This meant children were at risk of receiving inappropriate care.

The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We raised our concerns with the provider during the inspection who took immediate action to address the concerns.

A new team of assistant psychologists (APs) had been employed following our last inspection and were seen to have a positive impact on children’s care. For example, one child was demonstrating a new pattern of behaviour. APs worked closely with the child to better understand their needs. The APs then used this knowledge to create new ways of working with the child which were shared with the STC operational staff. We saw a positive improvement in the child’s outcomes following this work.

The healthcare service is situated within Oakhill STC and therefore does not take responsibility for the upkeep or health and safety of the premises. However, where repairs or replacement is required, there are systems in place to facilitate the work.

Despite this, the healthcare area of the STC appeared dull and unwelcoming. For example, the children’s waiting room contained only a wooden bench and lacked any child appropriate decoration.

Following our last inspection the provider increased the number of staff profiled to the service. Although recruitment was ongoing with some vacancies remaining, we found staffing levels adequate.

The provider had credible plans in place to clearly define the roles of nursing staff working in primary care and mental health including the recent recruitment of lead posts for both primary care and mental health. However, at the time of our inspection nursing staff were working across both disciplines.

Particular investment had been made to the mental health service with the addition of five APs which was having a demonstrable positive impact. Staff and managers employed by the STC we spoke with told us of the improvements the APs had made.

The provider had robust and safe recruitment practices in place to make sure all staff, were suitably experienced, competent and able to carry out their role. We reviewed 3recruitment records and found all appropriate checks had been completed and the process was fair and unbiased.

A thorough programme of training and development was in place for all staff. However, some staff told us they did not always have enough time to complete training. The provider recognised this and offered incentives including overtime to complete outstanding training.

Staff received regular supervision from their line manager. All staff we spoke with highly positive about the quality of support and supervision from their line manager.

The provider had a robust, safe and effective infection prevention and control policy in place. Staff we spoke with understood the need to adhere to the policy and what action was required as part of their roles.

Clinical areas were clean and free of clutter. Personal protective equipment (PPE) was in place and available to staff undertaking clinical work. We observed the safe use of PPE including its safe disposal.

Pharmacy services were provided by an agreement with a local pharmacy. They provided both stock medicines and dispensed children’s individual medicines. Children were allowed to possess and administer some of their own medicines, 82% of children were deemed safe to hold their medicines in-possession (IP), and there were appropriate in-possession risk assessments (IPRAs) in place.

Administration of medicines that were not being held in-possession occurred either at healthcare or in one of the clinical rooms on two of the house blocks. Systems were in place to safely store the medicines; however, it was difficult to tell from records whether children had received the medicines they needed. We found numerous occasions where the electronic records had not been completed. There were no reasons documented as to why children had not received their medicines. We saw that current prescriptions were not always in place on the electronic system, so the record was not accurate regarding what medicines children were taking. For example, one child who was asthmatic and had been reviewed in August 2025 by the GP and prescribed a preventer inhaler. There was no current prescription on the system for either the preventer or reliever inhaler.

We saw that paper records were still being used in houseblocks for staff to try and check whether the children had enough of their medicines. Staff checked with the children once per week and recorded it on a paper record kept in the drug trolley. Staff told us they had not had adequate training on using the electronic system.

We saw that there was sometimes a delay in repeat prescription requests on the electronic system which resulted in gaps in therapy. There was no record of escalation if children missed doses of their medicines. There was no time frame defined within the providers policy for missed doses of critical medicines to be followed up.

Effective stock management was not always in place; there was no effective audit trail of stock removed from the cupboard in healthcare. The cupboard contained a few items that may be required in an emergency such as inhalers, but these were not labelled appropriately to be given to children as they contained no directions for administration. Other items were not available in the cupboard such as antibiotics which led to a delay in starting therapy, we saw one child waiting more than 3 days for a supply of antibiotics. This was not in line with the medicines management policy which stated, ‘a robust audit trail of medicines leaving the stock cupboard must be maintained’ and ‘medicines must be labelled in accordance with normal labelling regulations should the medication be supplied in-possession to the patient.’

We saw logs of medicines disposed of maintained but there were no cytostatic bins available for the disposal of certain antibiotics or hormones.

A pharmacist visited once a month and remotely reviewed electronic records on a weekly basis. Children did not have direct access to the pharmacist for advice.

Medicines reconciliation is the process of identifying an accurate list of a person’s current medicines and comparing them with the current medicines in use, recognising any discrepancies, and ensuring any changes are documented. No medicine reconciliation was taking place, and the service was not using the established national template to record any discussions about children’s medicines. National guidance states this is to be completed within 72 hours of admission. There was no oversight to ensure this was in place. Staff did not have access to the necessary systems to enable this to take place (Summary Care Record or SCR). We were told this had previously been raised but no action had yet taken place. This was not in line with the provider’s policy.

The service had one emergency bag stored in healthcare which would not have been quick to access if needed on one of the house blocks. It contained the incorrect strength on adrenaline to treat anaphylaxis in older children and there was no medicine suitable to treat seizures. We were told the community nurse who ran the vaccination clinic brought their own emergency equipment with them.

Protocols were in place to allow staff to administer medicines for minor ailments, such as paracetamol or ibuprofen for pain.

Controlled drugs were stored, recorded and checked appropriately. The provider had identified they required a controlled drugs licence to hold stock midazolam for the emergency treatment of seizures.

We watched the procedure for sending medicines securely with a child when attending court, to ensure they had the medicines they needed. This was not recorded on the electronic system.

Monthly medicines management meetings had recently started in September 2025.

The concerns demonstrate a breach of Regulation 12 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We raised our concerns with the provider during the inspection who took immediate action to address the concerns.