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 assessment. We found there had been some improvement in the quality of incident reporting, but incidents were still not consistently reported. Staffing levels and deployment of staff had improved shortly before the inspection, prior to this primary care shifts were regularly short staffed. Following the inspection, the provider agreed to appoint additional temporary staff to ensure safer staffing levels were met. Medicines management was poor with a high proportion of patients not receiving their medicines on time. This included critical medicines. The team made us aware of enablement issues including insufficient dispensaries for the volumes of medications. Oxleas and NHSE had requested two additional hatches as part of the UN Action plan (2024) at the time of our last assessment, however works have not begun on these. 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.

The provider had not ensured all identified incidents were reported.

At the last assessment we found not all incidents had been reported or investigated in line with trust policy. During this assessment we found that whilst there had been an improvement in the quality of incidents reported, identified incidents had still not all been reported in line with trust policy. We found there were several incidents where staffing levels were not safe as well as a medicines incident, these incidents 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 assessment we found that there were insufficient staff deployed or effectively deployed to meet the needs of patients across primary care, including medicines administration. During this assessment we found that, the vacancy rate for primary care was above 40%. 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. A business case for additional staff to maintain safe staffing levels originally submitted to NHSE prior to the last assessment had still not been agreed.

At this assessment, there were expected to be 10 healthcare staff per shift within primary care, although this had agreed to be increased from 11 to 12 at the previous assessment. Most shifts were short of the expected number of staff, although this had improved in the 2 weeks prior to the assessment. Staff we spoke with reported on having an improved staffing complement making a huge difference. Following the assessment, management agreed to arrange cover from 4 additional agency nurses to maintain safer staffing levels until the business case is approved.

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

The medication lists used by prison officers were not always accurate, so people were unable to attend healthcare to get their medicines. Healthcare staff tried to ensure that all the relevant people attended by liaising with prison staff to ensure people were given the opportunity to attend.

There was access to medicines for minor ailments and there was out-of-hours provision for critical medicines, such as antibiotics. The oversight of these medicines was poor, balances did not match stock levels, and there was no evidence that these had been reviewed since May 2025. We saw that one medicine had been issued to a service user without the legal labelling and provision of the patient information leaflet, contrary to the provider’s policy.The critical list of medications was still under review and required updating in conjunction with Trust policy.

Medicine management audits were being completed monthly which checked whether medicines were appropriately stored, in date and secure. This highlighted that the emergency cupboard stock was not being reconciled appropriately.

87% of patients were in receipt of IP medicines, all had a risk assessment in place. In possession medicines were picked up from 3-5pm. Movement freezes remained on the risk register which affected patients’ ability to pick up their IP medicines, although staff told us this had improved recently.

However, we found numerous records where people had not received their medicines, including antipsychotics and diabetes medicines. We found one person who had not had their medicine issued to them to help prevent a chest infection. We found a delay of 5 days in issuing paracetamol to one patient with dental pain; this was no longer available to purchase from the canteen list.

88% of prisoners had a medicines reconciliation completed to ensure their medicines were continued appropriately once they entered the prison.

The system for getting repeat medicines prescribed and supplied was flawed. We saw that templates on the electronic system had run out leading to gaps in medicines administration such as HIV treatment, antipsychotics, mood stabilisers and in one case a service user missed 11 days of his cardiac medicines. This put service users at an increased risk of deterioration in their health.

When people missed medicines, we witnessed some good examples of escalation and witnessed staff trying their best to resolve problems during morning medicines administration. Sometimes medicines got ‘lost’ and these were not reported as an incident resulting in limited oversight.

The Kent Prisons Medicines Management Committee met every three months where audits, safety alerts and shared learning from incidents were reviewed.

Structured medicines reviews were being undertaken but due to staffing pressures only 13 had been completed annually.

Current figures showed that when leaving the prison only 77% of patients had a supply of their medicines.