HMP YOI Deerbolt

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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 assessed 1 quality statement under this key question. Governance of the service remained a concern. While progress had been made in areas such as the complaints process and the recording of in-possession medicines, further improvement was needed to develop and embed robust governance processes, particularly surrounding incident reporting, risk oversight, and monitoring of service improvement.

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 our previous inspection, we found that incidents were not consistently reported, which potentially limited the service’s ability to identify and analyse themes from incident data. This also reduced opportunities for learning and service improvement. We also raised concerns about the provider’s management and tracking of complaints and their resolutions.

At this inspection, we found that service users now had access to a confidential complaints process, which was clearly displayed throughout the prison. Responses to complaints were timely, with a strong emphasis on face-to-face resolution. The service received very few complaints from patients.

However, the mitigations and actions regarding incident reporting, as set out in the provider’s action plan, had not been fully implemented or embedded into practice. Incidents were still not always reported consistently or in line with the provider’s own expectations, with notable delays and omissions in recording incidents that should have been documented.

Although the service had introduced processes to track delayed or incomplete reporting, these mechanisms were ineffective and lacked sufficient oversight from service leaders.

Managers and staff told us about current incident reporting practices, and we identified inadvertent under-reporting as a result of this. For example, incidents involving individuals under the influence (UTI) were often grouped together under a single incident report, even when different individuals were involved. This practice presented several potential risks:

• It potentially limited visibility of the scale of substance misuse within the establishment, meaning patterns or spikes in drug-related activity might be missed.
• It reduced the accuracy of incident data, which in turn potentially affected the service’s ability to analyse trends, allocate resources, and plan interventions.
• It potentially limited opportunities for learning and service improvement, as individual case reviews were less likely to occur when incidents were grouped as it became difficult to search and recall incidents relating to specific individuals on the system.

Overall, these practices for incident reporting potentially undermined the service’s ability to generate meaningful intelligence and respond effectively to emerging risks.

The provider told us that supplementary ad hoc training had been delivered to support staff in correct incident reporting. However, the service was unable to provide evidence of this training. This lack of documentation did not provide assurance of effective information governance, accurate record keeping, or oversight of agreed improvement actions.

We reviewed minutes from governance meetings and found that key forums, such as the Clinical Governance and Quality Group, did not consistently fulfil their intended functions. Minutes were often brief and lacked sufficient detail to demonstrate robust discussion or critical analysis of service risks. There was limited evidence of trend analysis or clear articulation of actions and learning arising from incidents or audits. Meetings were not always held in line with expected schedules, and attendance by key personnel was inconsistent. As a result, these forums were not providing effective oversight or assurance.

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.