HMP Long Lartin

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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 looked at 1 quality statement in this key question. Governance systems had been strengthened and there were now a number of audits in place to effectively monitor the quality of services to patients.

However, during this inspection we found further concerns. Partnership working was not always effective in addressing long-standing environmental concerns, some assurance processes were not all working as expected, oversight of risk did not include those in the mental health team, and sexual health service records were not kept separately.

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.

At the last inspection there were insufficient audits and checks to monitor key aspects of the service at regular intervals. For example, there were no checks in place to monitor the quality of care records, and systems had failed to identify that some records were of poor quality. Several routine audits had been implemented by managers including for long term condition management, care planning, documentation standards and NEWS2 to monitor deteriorating patients. Audits we reviewed were thorough and included actions where a concern was identified, which was raised with the clinician in supervision.

When we reviewed patient records for those receiving wound care or treatment for a long term condition, we saw that records had been completed to a high standard with sufficient detail of care provided and action taken. We saw evidence that clinical decisions and prescribing were reviewed during the safer prescribing and multi-professional complex case meetings.

At the last inspection we found that some delegation of tasks were inappropriate and did not facilitate effective oversight of the services’ activities. Through observations and conversations with staff we found this was no longer a concern, and there were no tasks which we found to be inappropriately allocated.

We saw that clinicians reviewed patient applications to see a member of the healthcare team, which ensured appropriate clinical oversight. There was a clear process in place for a dedicated staff member to action any urgent requests each morning. Staff appeared clear in their responsibilities, and this was also reflected in the team’s emergency response to incidents. We saw two examples of nurses responding to emergency calls from the prison in a timely manner and the appropriate recording of the incident on the patient record which included body mapping.

During this inspection, we found the dedicated end‑of‑life suite and inpatient unit were still not fit for purpose, as identified in a previous inspection with His Majesty’s Inspectorate of Prisons. Admissions by the prison were not always aligned with the defined healthcare criteria for the unit, and the environment remained unsuitable due to infection control concerns and periods without heating or hot water. A stairlift that had been broken for over a year meant that patients with limited mobility could not safely access the in-patient unit and some healthcare clinics. Although the repair of these issues was outside of the providers direct control, they posed an ongoing risk to patients’ health and wellbeing.

We did not see sufficient evidence that partnership arrangements were being used effectively to address these long‑standing environmental problems, which also included infection prevention and control issues, and unsecured medicines trolleys. These risks had not been consistently escalated or acted on at a strategic level.

Additionally, assurance processes had not picked up expired or incorrectly stored items in emergency bags. We also found the risk register was not managed effectively, because some risks within the mental health teams, such as limited psychiatry provision and a lack of suitable consultation space had not always been identified, assessed or recorded. When actions were taken, these were not always documented.

CQC did not receive a statutory notification about a heating and hot water failure between 26 December 2025 and 7 January 2026 for the in-patient unit and all of healthcare. This incident prevented or was likely to prevent them from delivering regulated activity safely and in accordance with the fundamental standards of care. The ongoing failure of the stairlift and hoist also affected access to care for people with limited mobility. The impact on patients and staff was not recorded well, and there was little evidence of actions taken to reduce risks to people’s health and wellbeing. For example, when we reviewed the records for 4 patients on the in‑patient unit during this period, there was inconsistent documentation of their health monitoring and room temperatures, meaning risks may not have been identified or addressed.

We found that a sexual health service was available, providing care and advice within the prison, although uptake was low. There were good working relationships with secondary care specialists. Patients could access this confidentially, but records were not stored in a standalone confidential system, which was not in line with national guidance.

Following our inspection, the provider told us they would review their governance arrangements and ensure statutory notifications were submitted promptly in future.

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.