HMP Durham

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 looked at 1 quality statement in this key question. Governance arrangements had improved in relation to the administration team processes for patient applications and oversight of the EPCU.

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.

Following our inspection in June 2025, Spectrum implemented a range of effective improvements to enhance staff awareness and managerial oversight of the Enhanced Primary Care Unit (EPCU). In addition to dedicated EPCU staff, senior nurses within the primary care team demonstrated a clear understanding of their responsibilities, including oversight of staffing levels and skill mix to ensure patient needs were met safely and effectively.

To further strengthen governance arrangements, managers introduced a quarterly audit to provide assurance that safe processes were in place for admissions to the EPCU. Between 1 January to 31 March 2026, compliance was 87%. Areas for improvement were identified, particularly in relation to completion of the admission template and timely recording of clinical observations within four hours. An associated action plan was in place to monitor progress and track improvement.

Spectrum also revised the local staff induction programme to include a dedicated section on the EPCU. All new staff were required to complete a competency-based assessment, delivered by senior nurses, which covered key aspects of EPCU practice, including patient admissions, ongoing clinical monitoring, and participation in ward rounds.

The newly introduced SOP for managing patient applications was well embedded in practice. Administrative staff had completed competency-based training to support them in this role, and responsibility for managing applications was shared across team members to maintain competence and consistency.

In addition, the administration manager had introduced a tracking system to improve oversight of patient activity, including the number of applications received, appointments scheduled, and instances of non-attendance. This information was accessible via Spectrum’s online performance dashboard, supporting ongoing monitoring and service improvement.

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.