HMP Leeds

On this page

• 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 1 quality statement under this key question. We found that the service had several governance structures, forums and audits in place that supported oversight of key service functions. While many of these processes operated effectively, we identified weaknesses in the governance arrangements for monitoring and tracking pathology results. Processes were not always consistently followed, and gaps in the audit process led to delays in the follow‑up of some patients’ results. Although the service had begun to strengthen these processes, the improvements had not yet been embedded or tested. As a result, the service was in breach of Regulation 17 (Good governance).

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.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

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.

During the inspection, the service demonstrated a range of governance processes, forums and audits that contributed to oversight of its key functions. We saw several examples of effective governance in practice, including the clinic cancellation audit, daily senior management meetings, quarterly medicines management meetings and the audit of non‑emergency AE transfers. These mechanisms provided leaders with regular insight into performance and supported service improvement.
However, we identified that governance systems and processes relating to the monitoring and tracking of patients’ pathology results were not always operating effectively or reliably. The service maintained an audit intended to monitor the timely receipt of test results, but the quality and consistency of its completion varied. The level of detail recorded did not provide sufficient assurance that results were routinely received or reviewed in a timely manner, and we saw examples where individual patients’ pathology results had not been followed up promptly, leading to delays in clinical review.

During the inspection, the service had begun taking steps to strengthen these assurance processes, including revising the audit template. However, these improvements had not yet been embedded or tested to demonstrate their effectiveness. In addition, although processes for following up external pathology results had been communicated to staff, a formal local operating procedure had not yet been ratified or issued to support consistent practice.

The shortfalls identified in the governance processes for monitoring pathology results constituted a breach of Regulation 17 (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.