HMP Fosse Way

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 2 quality statements for this key question. We found the provider did not have effective governance systems in place to identify, assess and address the full range of risks.

While healthcare services at HMP Fosse Way were improving, particularly since the appointment of a new Head of Healthcare in January 2026, significant concerns remained. Leaders demonstrated a clear understanding of the challenges facing the service, including historic staffing shortages, governance gaps and high mental health demand. However, some areas of concern had not been included in the service improvement plan, such as the management of patients’ medicines and mental health services.

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

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

Healthcare services at HMP Fosse Way were on a positive improvement trajectory, supported by strong leadership and a committed workforce, however it was too early to see the impact of this across all areas of the service.

An experienced, capable and knowledgeable head of healthcare had been in post for around 8 weeks and had been successful in implementing new policies and procedures which had significantly improved some areas such as substance misuse services. Staff consistently spoke positively about the head and deputy head of healthcare, describing them as transparent, focused and effective.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Audit processes had been significantly strengthened. While audit activity had been limited prior to January 2026, a full national audit programme was now in place, with clear leadership and accountability.

We found patient records were not always accurate, complete and contemporaneous. We identified several examples where patient records lacked sufficient detail, making it difficult to clearly understand the clinical rationale for care provided. This was particularly evident in the recording of medicines administration, including the use of homely remedies, where the reason for treatment and clinical decision-making was not always documented. In some cases, there was limited or no evidence of a clear treatment plan, and follow-up actions, including appropriate referrals, were not consistently recorded. This created a risk that patient care may not be sufficiently coordinated or reviewed, and that important clinical information may not be accessible to other staff involved in the patient’s care. Leaders were aware of these issues. They told us that regular dip-sampling of clinical records was undertaken. We saw evidence where these checks had identified gaps in recording, including instances where medicines administration had not been documented. While this demonstrates emerging oversight, it had not yet resulted in consistent improvements in record keeping practice.

Senior clinical staff spoke positively of the provider’s quarterly face to face meeting which provided an opportunity to meet staff from other sites, and share learning and ideas. Staff felt the daily handover meetings and weekly multi-disciplinary complex case meetings were effective forums with good information sharing and the opportunity to discuss individual patients.

Leaders had oversight of risks and used the risk register effectively. Risks were reviewed regularly, and there was evidence of progress in mitigating them. However, the medicines management risks we identified during our inspection had not been sufficiently reflected on the risk register and required closer scrutiny. This meant there was a risk that significant issues were not being fully recognised, prioritised or addressed in a timely way, potentially impacting on patient safety and the effectiveness of governance arrangements

A comprehensive service improvement plan was in place and was driving measurable improvements across the service, including improvements in secondary health screening rates, hospital escorts, task management, and vaccination delivery. However, the improvement plan had not captured all issues we identified during the inspection. For example, pharmacy actions such as supply issues, auditing of blank FP10 prescriptions and in-possession medicines administration recording issues were not included. There were also some concerns recorded on the action plan around mental health triage, but it was not clear why these actions had not been addressed sooner given the length of time they had been known to the provider.

Staff were unable to clearly describe the systems in place to ensure that patients attended scheduled appointments or that required follow-up actions were completed. There was no effective process to monitor or review pathology results in a timely manner, creating a risk that abnormal findings might not be identified or acted upon promptly.

In addition, there was no clearly defined local mental health pathway to guide staff in the assessment, management and ongoing care of patients requiring mental health support.

These widespread gaps in governance processes meant that the provider could not be assured that risks to patients were being effectively managed. We found these concerns to be significant, and they contributed to breaches of regulations relating to safe care and treatment and good governance.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.