HMP YOI Rochester

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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 for this key question. The provider had not made sufficient progress with the identified regulatory breaches. Some improvements had been made and we found that there was much improved oversight of external hospital escorts. We found there were systems and processes in place to manage and learn from current and future performance and risks to the quality of service. However, managers and staff had not consistently followed these processes. Incidents were not consistently reported, audits lacked any meaningful follow-up or improvement work and there was a lack of oversight for access to patient appointments.

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.

The service had a process in place to report safety incidents. Staff recognised incidents but these were not consistently reported.

At the last inspection we found staff were not consistently reporting incidents and they were often poorly written. Additionally, the level of risk did not always reflect the severity of an incident in accordance with trust policy.

During this inspection we found there was improvement in the quality of the incident reporting, however, medicines incidents and staffing shortages were frequently not reported. Some of the staff we spoke with told us they did not have time to report all incidents because of staffing pressures.

The service had oversight of the management of external hospital appointments.

During the last inspection there was a lack of oversight to ensure patients attended or were re-booked to attend external hospital appointments.

During this inspection we found the spreadsheet was completed fully and the daily ledger updated with details of hospital attendances. The administration team ensured the process operated well and we found significant improvement.

Staff participated in local audits; however, audits were not utilised to improve patient safety or performance. Examples of audits included care plan audits, medication audits and infection control audits. An audit plan was in place, and we were provided with examples of some audits. Weaknesses were identified in the audits, however, management had not developed an action plan or taken any immediate mitigating action in response to the findings.

The service had identified risks and documented mitigating controls. However, these were not consistently being monitored to ensure they were put into practice.

At the last inspection we found the risk register did not reflect risks faced by the healthcare department and this was out of date.

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.