HMP YOI Doncaster

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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 2 quality statements for this key question. We found that staff training and supervision had improved. Processes for medicines had improved but there continued to be concerns about room temperatures, out of hours medicines register and second checking of medicine administration.

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

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

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

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.

At our previous inspection we found gaps in staff supervision for mental health staff and training compliance for intermediate life support (ILS) and safeguarding.

At this inspection we found that compliance with mandatory training was much improved and staff had either completed the required training or were booked on to the course.

Clinical supervision compliance, in line with the provider's policy, had improved. Data from November 2025 to July 2026 showed an average compliance of 82.5%.

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

At our last inspection we found that medicines management second checking practices were inconsistent.

At this inspection we found that provider had undertaken a comprehensive review of medicines management second-checking practices which included reinforcement of expected practice standards and implementation of monthly assurance checks for compliance. However, during our review of the Controlled Drugs (CD) registers, we identified 6 occasions where a medicine had been recorded as witnessed during administration, but there was no corresponding signature from the person who had administered the medicine. As a result, it was unclear what the witness signature was verifying. We found that the second checker would sign the register at the point of administration to confirm they had witnessed the medicine being given, with the administering member of staff signing the register retrospectively at the end of the administration session.

At our previous inspection we found that there was no record or audit trail for the supply of out-of-hours medicines.

At this inspection, we found that an out-of-hours medicines register had been implemented to strengthen governance and accountability. The provider told us that the register would be subject to monthly assurance checks, with ongoing weekly monitoring to support compliance.

We found a number of discrepancies and omissions within the out of hours medicines stock register, meaning medicines could not always be fully accounted for. For example, records for Apixaban showed a stock balance of 100 tablets on 27 July 2026 and 93 tablets on 11 August 2026, with no documentation to explain the discrepancy of 7 tablets and no corresponding incident report completed. Other issues identified included the failure to record the destination of medicines transferred between locations, entries documenting the removal of a "box" of medicines without specifying the quantity of tablets involved, the register showed that medicines had been received from pharmacy without the quantity being recorded, and staff did not sign every entry, instead they used ‘ditto’ marks. In total, we identified 11 record-keeping errors or omissions during our review. These findings demonstrated that the monitoring arrangements introduced by the provider had not been effective in identifying and addressing inaccuracies within the out of hours medicines register, resulting in ongoing risks to the safe management and accountability of medicines.

At our previous inspection we found that fridge and room temperature checks were inconsistently recorded and there was no evidence of action taken in response to consistently high room temperatures in medicines administration rooms. This was not on the service risk register.

At this inspection, we found that air conditioning units had been installed in medicines administration rooms to help maintain appropriate ambient temperatures for the safe storage of medicines in line with PPG policy. We found staff were consistently recording room and refrigerator temperatures. However, our review of temperature records for the House Block 1 medicines administration room showed that between May 2026 and the date of inspection, the recommended room temperature was exceeded on 95 of 137 days reviewed (69.3%). This included every day in September 2026 (14 out of 14 days), indicating a sustained and ongoing failure to maintain temperatures within the required range. There was no evidence that action had been taken when room temperatures exceeded 25°C to ensure the efficacy of the medicines stored. We also found that staff were not following the most up-to-date standard operating procedure, escalating the risk or using the required documentation.

The provider told us that weekly and monthly monitoring checks would be introduced, with findings discussed at handover meetings. However, given the frequency and duration of the temperature breaches there was limited assurance that the existing governance arrangements had been effective in identifying and addressing the risks associated with medicines storage.

At our previous inspection we found that pharmacy technicians did not consistently ask for ID cards during medicines administration rounds.

During this inspection, we observed 2 medicine administration rounds and found that pharmacy technicians routinely requested patients’ ID cards before supplying medicines. Where patients attended without their ID card, they were asked to retrieve it before their medicines were issued.