HMP Leeds

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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 4 quality statements under this key question. We found that there were sufficient numbers of qualified, skilled and experienced healthcare staff on duty to meet the needs of the prison population. Medicines were managed effectively, and patients received their medicines in a timely manner. The service demonstrated a strong and positive learning culture that supported service improvement and positive patient outcomes. The service had also taken assertive action to monitor, manage and reduce delays to non‑emergency patient transfers to A&E.

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

The service demonstrated a strong and positive learning culture. Staff routinely used the incident reporting system to record operational and patient safety incidents. Reporting levels and the level of detail within reports indicated that staff felt confident to raise concerns and understood their responsibilities in doing so.

Governance structures supported a systematic approach to learning. Senior leaders, together with the regional patient safety team, had clear oversight of all reported incidents. They reviewed incidents, oversaw investigations, and ensured that opportunities for organisational learning and improvement were identified. Where improvements were required, action plans were developed with defined ownership and oversight to support implementation.

Thematic analysis and learning from incidents were discussed through established governance forums, including the quarterly Patient Safety Incident Reporting Group (PSIRG) and the bi‑monthly local quality assurance meetings. These forums enabled leaders to identify trends, monitor progress against actions, and share learning in a structured way.

Learning and feedback from incidents were shared widely across the workforce. The service benefited from a national and regional patient safety team, who worked strategically across multiple sites to share learning from incidents and best practice. This supported local teams to proactively review their own processes and make changes to reduce the likelihood of similar incidents occurring.

Staff told us that learning was shared through daily handovers, team meetings, and email communication. This supported timely sharing of information, helped staff understand changes in practice, reinforced organisational expectations, and contributed to an open and transparent culture focused on improving patient outcomes.

During the last inspection, we identified delays for patients who required non‑emergency transfer to A&E, largely due to shortages in prison staffing. During this inspection, we found that the service had taken action and was working closely with the prison’s senior leadership team and wider system partners to monitor, manage and reduce delays.

A local operating procedure (LOP) was in place, clearly outlining staff responsibilities for the assessment, management and escalation of patients requiring transfer to A&E. The LOP detailed who clinicians should contact to arrange transfers and set out a stepped escalation process through prison management. Where a same‑day transfer could not be facilitated, the service’s process required ongoing clinical assessment of the patient, completion of an incident report, addition of the patient to the safeguarding log, and inclusion in a tracking audit to maintain oversight of delays to treatment.

Senior leaders attended the prison’s daily operations meeting, where they provided updates on patients awaiting transfer, including clinical risks and the duration of delays. A written list of patients awaiting transfer was also supplied to ensure shared oversight and accountability.

The service utilised unused planned escort slots to support transfers, which had reduced delays in access to treatment. In collaboration with prison, the service had developed a business case to NHS England to increase the number of planned escort slots available each day, although outcomes from this remained in progress at the time of inspection.

The service was aware of themes from transfer activity and identified that patients often self‑discharged from A&E due to long waiting times. This had implications both for patient care and prison staffing, as it increased the need for additional transfers. In response, the service sought to book planned care where possible, including through the hospital’s Same Day Emergency Care service which offered a more manageable and efficient treatment pathway when same‑day transfer was unlikely, or self‑discharge was anticipated.

The service had also introduced regular meetings with the prison’s security department to strengthen partnership working and address challenges associated with non-emergency transfers. These meetings supported joint problem‑solving and helped partners work collaboratively to reduce delays and improve patient access to urgent assessment and treatment.

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.

The judgement for Safe environments is based on the latest evidence we assessed for the Safe key question.

During the last inspection, we found that there were insufficient numbers of healthcare staff deployed on shifts to ensure the safe care and treatment of patients. At this inspection, we found that improvements had been made.

The service had recruited to their vacancies and was monitoring new starters as they progressed through final onboarding and security vetting checks.

A review of the service’s rotas showed that the service’s optimum staffing levels had been met for the majority of shifts. Rotas were planned on a quarterly basis, giving staff adequate notice of their working patterns and enabling leaders to identify and address rota gaps in advance.

Leaders told us that occasions where staffing did not meet optimum levels were due to unplanned staff sickness. We saw that established processes and guidance were in place to support shift leaders in managing any shortfalls, including clarification of clinical priorities and escalation routes to secure additional staffing.

Although some primary care staff continued to support with social care staff duties, rotas and allocations were not planned on this basis, and we did not find evidence that this occurred frequently or that it regularly impacted the delivery of primary healthcare.

To maintain safe staffing levels and cover rota gaps, the service used a core group of bank and agency staff. These staff were familiar with the service, which supported continuity of care.

Leaders planned job allocations in advance, and staff worked collaboratively to share complex care tasks, supporting both service delivery and staff wellbeing.

Staff told us that staffing levels had improved and reported confidence in their team’s ability to work collaboratively in the best interests of patients.

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

During the last inspection, we found that processes used within the electronic patient record (EPR) increased the risk of patients not receiving critical medicines on time.

At this inspection, we found that the service had changed the processes used within the EPR. Medicine and prescribing requests were now managed through the system’s tasking function. This provided prescribing clinicians and the pharmacy team with improved oversight of medicine‑related actions. Urgent or critical medications were flagged to indicate their urgency, and staff routinely added due dates to tasks, enabling them to be prioritised effectively and supporting efficient workload management by both prescribers and pharmacy staff.

Processes were in place to support daily oversight and monitoring of outstanding tasks, enabling timely escalation and resolution. Outstanding tasks were discussed during the daily senior management meeting, which we observed.

Staff told us the revised processes were working well and that they felt confident patients were receiving their medicines in a timely manner.

Quarterly medicines management meetings were held, providing an essential forum for discussing medicines’ governance, reviewing themes and learning from medicines‑related incidents, monitoring service performance, and identifying areas for improvement. Attendees also reviewed local and standard operating procedures and agreed actions to support ongoing service development. We observed one of these meetings and saw that it functioned as intended, providing effective oversight and governance of medicines.