HMP Fosse Way

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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 6 quality statements for this key question. We found risks to patients were not always assessed, monitored or managed effectively.

The service did not always have appropriate systems and processes to safely prescribe, administer, and record medicines, and some administrative processes lacked oversight.

However, we found evidence of a strong learning culture, and safeguarding arrangements were robust. Staffing levels were improving significantly but remained a challenge.

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

There was a learning culture within the service. Staff understood their responsibilities to raise concerns and felt encouraged by leaders to do so. Incidents, including deaths in custody, were reviewed appropriately and learning was used to drive improvement.

A clear process was in place for staff to report and investigate incidents on an electronic system, Datix. All incident reports were reviewed by a senior manager and allocated to a lead investigator within 72 hours. Outcomes were reviewed and staff could request feedback. Incident themes were discussed at quarterly assurance meetings, regional meetings and escalated nationally where appropriate.

Learning was shared through daily staff “buzz” meetings and targeted training. For example, controlled drug errors had led to additional pharmacy-led training, and a security breach involving keys prompted joint learning with prison staff. We reviewed 6 Datix incidents, all of which had been managed in line with policy, with evidence of learning. Staff spoken with described a strong reporting culture and provided recent examples of incidents they had raised.

Following deaths in custody, new policies had been introduced, including a strengthened omitted dose policy and additional training to support staff in recognising and managing high blood pressure. These changes demonstrated learning from serious incidents.

Healthcare staff worked together to support around 100 new patients arriving at the prison each week. Patient records showed that patients received an initial reception health screening on the day of arrival and a secondary screening within the recommended 7 days. These records were completed to a good standard, and appropriate referrals to other services such as mental health or substance misuse were made promptly.

Managers were in the early stages of developing an early days in custody pathway to include a daily multi-disciplinary meeting to review all new arrivals to the prison from the previous day. The aim was to bring together staff from all areas of the service to proactively identify patient needs and action these from the earliest opportunity.

Although there were no patients in receipt of a social care package at the time of our inspection, pathways had been developed with the local authority to ensure referrals, assessments and care could be provided if required. The primary care lead attended a monthly meeting with the prison and local authority to maintain relationships and monitor patient referrals.

There were systems in place to manage patient correspondence. Administrators completed scanning daily to prevent a backlog and the management of tasks had improved significantly with only 78 administrative tasks outstanding at the time of our inspection. Managers had daily oversight of tasks to ensure these did not increase and become unmanageable for staff.

Administrative staff processed patient referrals; routine referrals were completed within 1 day and no urgent referrals were outstanding during the inspection. Referrals were recorded on an electronic system to monitor figures of referrals booked, completed, and cancelled. However, there was no audit process to ensure that referrals had been sent which meant that if a referral was missed this would not be identified and could delay patient care.

We found there was no system to ensure that follow up actions were completed for patients returning from external hospital appointments. Patients were seen when returning to the prison by a nurse, however there was no oversight of follow up care required which created a risk that patients might not receive the appropriate care.

There was no reliable system to monitor and review pathology results daily. We found 2 service users whose results had been waiting for review for 4 days and 1 for 6 days. This meant there was a risk that patients may experience a delay in receiving the appropriate care in line with their test results.

Safeguarding arrangements were effective and well embedded. There was a prison-specific safeguarding local operating procedure, and all staff we spoke with understood how to report concerns.

Two safeguarding leads were in post, with advanced level 4 safeguarding training scheduled for them. All staff, including administrative staff, had completed level 3 safeguarding training.

Safeguarding concerns were logged, tracked and overseen appropriately. We reviewed a sample of referrals and found appropriate actions had been taken, including referrals to the prison safer custody team, incident reporting and escalation to external agencies where required. Examples included recent referrals to PREVENT (part of the government’s counter-terrorism strategy) and children’s social care.

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.

Staffing levels were improving but remained a challenge. When the provider took over the service in July 2025, vacancy rates were 57%; by April 2026 this had reduced to 17%. There were 21 staff onboarding at the time of our inspection, with the 18 remaining vacancies being actively advertised.

The provider continued to rely on agency staff, although their usage was reducing. Leaders had plans in place to further reduce agency hours, including the introduction of a set rolling rota for staff. Night-time staffing had been strengthened, with registered clinicians and healthcare assistants now available, improving patient care and access to medicines.

Despite the challenges, staffing levels had not fallen below minimum safe levels. Staff reported that improved staffing had led to better continuity of clinics, improved medicines administration and more time to complete incident reports.

Recruitment processes were robust. Personnel files showed that appropriate pre-employment checks had been completed, including DBS checks, references, professional registration and occupational health clearance.

Staff induction arrangements were comprehensive and included shadowing across different service areas, competency sign-off and regular review with regional teams. Staff we spoke with described their induction positively.

Mandatory training compliance was generally good. While overall compliance was reported at 88%, this did not fully reflect recent training completion. Most key clinical training areas showed high compliance. Most staff felt they had opportunities for training and development and felt well supported professionally and personally, but some staff did not feel they had received guidance on the provider’s policies and procedures since the contract changed in July 2025, and some felt they did not have time protected to complete required learning.

Clinical supervision compliance was reported as 100%. However, supervision arrangements for healthcare assistants were not yet fully embedded. Leaders were aware of this and had plans in place to address it through a newly appointed clinical lead. In primary care, we received consistently positive feedback about the culture as well as working relationships.

The provider had an infection prevention and control (IPC) lead at both local and organisational level. The local IPC lead was due to start role-specific training. Staff received the appropriate IPC training for their roles. IPC audits were carried out as part of the provider’s annual audit schedule with the latest one completed in February 2026. Several issues were generated from the recent audit and actions to address these were being overseen by the primary care leads. These included the introduction of formal hand hygiene spot checks and checks that staff complied with infection control requirements.

Treatment rooms and clinical areas were visibly clean and tidy. The provider had appropriate arrangements for managing clinical waste, which was collected regularly by an external provider. Sharps bins were labelled correctly, although not all were secured on wall brackets.

We found that the provider was not ensuring the proper and safe management of medicines. Electronic records were not always completed or accurate, and we found a lack of follow up actions taken in response to identified clinical risks.

Medicines were supplied by an off-site pharmacy, and administration occurred at 9 medicines administration points (MAPs) across the prison. Medicines were administered twice a day at 8am and 4.30pm, although pharmacy staff were available from 7am to 6pm. There was a high use of agency staff whilst awaiting 3 newly recruited staff who were going through the onboarding process.

Patients’ privacy was maintained during medicine administration and healthcare staff treated people with dignity and respect. We witnessed staff trying to ensure that all patients attended for their medicines including calling them by telephone if they didn’t attend.

We identified significant shortfalls in the management of patients’ medicines which posed a risk to their safety. Patients collected their in-possession (IP) medicines during the afternoon; we found that electronic records were poor and did not always show whether patients had received their medicines, including critical medicines. We also found that when patients returned from hospital, not all records were completed accurately to document medicines retained in-possession, creating a risk that patients would have double doses of medicines.

We found records relating to insulin prescribing and administration were incorrect which made it difficult to tell whether patients had received their insulin appropriately. Patients told us they had not received insulin when they needed it and in records we reviewed, it was not possible to identify whether the correct dose had been administered.

On 2 occasions, we found 2 weeks supply of in possession tradeable medicines could not be accounted for. They had been dispensed by the pharmacy but were not available when people came to collect them and the provider was not able to locate them in the prison. The provider assured us they would report these as incidents and open an investigation.

Sometimes medicines were unavailable for administration because they were out of stock. For example, we found one patient missed 9 days of a medicine for restless leg syndrome and another patient missed 12 days of a medicine to treat a heart condition. A third patient was prescribed pain relief in liquid form but had been unable to take this because the bottle had been broken 2 weeks earlier and not replaced. This resulted in patients experiencing ongoing pain and discomfort.

Records relating to controlled drugs were being completed correctly, however we found examples of medicines which had been stopped but continue to be prescribed in the electronic system. The patient had not collected these medicines but there was a risk medicines could have been administered unnecessarily.

There was no monitoring of patient allergies in relation to medicines they received. One patient was prescribed medicines containing lactose despite the electronic record clearly stating the patient was allergic to lactose. This had not been identified until inspectors raised concerns, and resulted in ongoing discomfort for the patient who was experiencing abdominal symptoms.

At the time of our inspection, 98% of patients had a medicines reconciliation completed on entry to the prison to ensure their medicines were continued appropriately. 83% of patients were in receipt of in-possession (IP) medicines, and all had a risk assessment (IPRA) in place, although prescribing did not always match the IPRA which staff told us contributed to the issues with recording the collection of in-possession medicines.

The pharmacy team had set up a robust referral pathway for HIV positive patients to ensure a reliable prescribing and supply chain for their medicines with the local trust although administration was not always recorded accurately within the electronic record.

There was an out‑of‑hours system to access some critical medicines, such as antibiotics, on the early days house block. There was access to medicines for minor ailments, and an accurate record when these medicines were removed was maintained, but we found that supply of these medicines was not always recorded in the patients record. We saw one patient repeatedly access paracetamol and this was not captured in his record. The critical list of medicines was not available for staff to easily view.

Staff carried out cell checks, with 12% of patients prescribed in-possession medicines receiving a check in February 2026. However, staff told us these checks had since decreased due to the increased use of agency staff who could not complete this work as they did not carry prison keys.

Medicines management meetings occurred regularly, where incidents, learning and improvement actions were reviewed. Although some audits took place, those for the medicines administration points were not completed consistently in line with the provider’s policy.

Current figures showed that when leaving the prison or attending court 82% of patients were given a supply of their medicines and those transferring out had medicines supplied 70% of the time. This had steadily improved under the leadership of this provider.

Access to prescribing stationery was controlled, and prescriptions were stored securely, but tracking was inadequate and staff were unable to account for all the prescriptions held within the service. Action was taken to address this when raised with the provider during the inspection.