HMP YOI Rochester

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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 3 quality statements for this key question.

The provider had not made sufficient progress to address the regulatory breaches found at our previous inspection. We found there had been some improvement in the quality of incident reporting but incidents were still not consistently reported.

We found systems to ensure patients attended external hospital appointments and were discharged safely to other services did not work effectively.

Staffing levels and deployment of staff had seen no improvement, primary care shifts were regularly short staffed, and management continued to work clinically on a frequent basis to help fill gaps in the rota. There were insufficient GP sessions to meet the needs of the population.
Medicines management was very poor with approximately half of all patients not receiving their medicines time, sometimes there were delays of days or weeks. This included critical medicines. We found incidents were not consistently reported in line with trust policy.

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

Incidents were reported by staff consistently.

At the last inspection we found not all incidents had been reported or investigated in line with trust policy. During this inspection we found that whilst there had been an improvement in the reporting of incidents, not all incidents had been reported in line with trust policy. We found there were several incidents where staffing levels were not safe and management regularly stepped in to work clinically, we also identified a number of medicines incidents which had not been reported using the trust’s internal reporting system. Staff we spoke with told us they did not always have time to report incidents. This meant that appropriate investigations and learning had not taken place to improve patient safety.

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.

The service was not staffed safely.

At the last inspection we found that there were insufficient staff deployed or effectively deployed to meet the needs of patients across primary care, including medicines administration. There were 11 healthcare staff per shift within primary care and following the inspection, management agreed to increase this to 12 Monday to Friday until a new business case had been approved.

During this inspection, we found that whilst some positions had been recruited to, shifts were frequently short staffed and the agreed number of 12 staff had reduced back to 11, although a business case had still not been approved. In February 2025, the prison had been reconfigured so that a significant number of patients were prisoners convicted of sexual offences (PCOSO). This placed the existing healthcare service under additional challenges because PCOSOs typically have more complex healthcare needs than the general population. During the inspection, staff and management told us managers regularly helped out clinically due to a lack of staffing. Records also showed that patients did not receive their medicines in line with their prescription and patients had long waits to see the GP. At the time of our inspection, the service had recently submitted a business case for a permanent increase in primary care staff as well as GPs and were awaiting a response.

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

The service did not have appropriate systems and processes to safely prescribe, administer, and record medicines.

Medicines were supplied by an onsite pharmacy with administration occurring from two healthcare treatment rooms. Patients receiving medicines to treat substance misuse were only able to obtain these from one location and methadone was pre-dispensed and transported to the second location to allow administration, which was unsafe. The pharmacy served 8 prisons in the area, on weekdays only.

There was access to medicines for minor ailments and there was out-of-hours provision for critical medicines, such as antibiotics. These medicines were labelled correctly and recorded appropriately.

Morning medicines administration was from 8am-10am and patients could pick up their In-possession (IP) medicines from 11am. There were 56% of patients in receipt of IP medicines and 93% of these had an IP risk assessment in place. However, this regime for administration wasn’t suitable for some patients as they were unable to attend at that time due to other commitments. This resulted in high numbers not attending for their medicines, including critical medicines. This was reflected in audit reports and remained on the providers risk register.

Patients complained that they did not receive their medicines on time, and we found numerous records that confirmed this. This included critical medicines, medicines to safely manage long term conditions, antidepressants, anti-seizure medicines, antihistamines, and medicines to help sleep. One patient had not received antibiotics which then resulted in admission to hospital.

Pharmacy staff were not aware of the complaints made by patients about their medicines.

When people missed critical medicines, in some cases there was no evidence of escalation. The critical list of medicines was currently under review as it had been identified there were some omissions from the list.

We observed administration that was chaotic, with staff having trouble locating medicines and administration did not run to schedule due to the prison regime.

There was no privacy for patients during administration and patients and staff had to bend down to waist height to speak through the poorly designed gap in the screen.

There was a significant number of patients receiving controlled drugs and we found contemporaneous records were not being completed in line with policy. This stated entries must be made immediately following administration by both members of staff and not left until the end of the medicines administration session.

Medicines were provided in a pouch system for those receiving their medicines in individual doses as per their prescription, however some items were not removed when temporarily stopped before giving to patients.

No action had been taken when the refrigerator in the treatment room had deviated from the required temperature for safe storage of medicines. The provider’s risk register reflected that both healthcare treatment rooms and refrigerators continued to record high temperatures.

Staff did not always complete incident reports and told us the process took too long. Sometimes medicines got ‘lost’ and this was not reported as an incident, so there was limited oversight to know how often this was occurring and any remedial action taken as a result.

A Kent prisons medicines management committee met every 3 months where audits, safety alerts and shared learning from incidents were reviewed.

Structured medication reviews were being undertaken but due to staffing pressures only approximately 3 were being completed every month.