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 2 of the 3 regulatory breaches found at our previous assessment. We found there had been improvement in the quality and rate of incidents being reported and investigated.

Staffing levels and deployment of staff had improved significantly since the previous inspection; however they still fell short on a number of shifts covered each month. The establishment had increased following commissioner approval of a business case and most positions had been appointed and were awaiting security clearance. Medicines management systems and processes had improved; however, some patients had not received their medicines on time.

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

At the last assessment we found not all incidents had been reported or investigated in line with trust policy.

During this assessment we found significant improvements in the reporting culture. Management had provided staff with additional training sessions on incident reporting, and we saw that there was improved reporting. Reported incidents were investigated and where necessary further learning was provided for individuals as well as short lunchtime learning sessions for groups of staff.

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, there were expected to be 10 healthcare staff per shift within primary care. Most shifts were short of the expected number of staff. During this assessment we found that there was evidence of some improvement, whilst shifts continued to be short of staff on a regular basis, the shifts had a higher fill rate for most shifts than the previous assessment. Vacant positions had been recruited to and staff had commenced, although there were a high number of new starters, managers were providing additional support to new staff. We noted that some daily tasks were not always completed when staffing numbers were low.

The commissioners had also approved a business case to increase the staffing establishment, creating a number of new positions in a variety of roles, including frontline staff as well as administrators and more senior nurses. These new positions had been recruited to and were awaiting security clearance at the time of the inspection.

We also observed improved communication between the healthcare staffing group as well as improved relations with officers which meant that the service was able to operate more effectively.

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

The service did not always have appropriate systems and processes to safely prescribe,administer, and record medicines, however feedback from staff reported that it had significantly improved since our last inspection and we saw a reduction in the number of missed medicines.

Medicines were supplied by an onsite pharmacy and administration occurred from 2 healthcare treatment rooms. The ‘bottom’ healthcare hatch continues to be unsuitable as people had to bend down to shout through gaps in the plastic screen, which compromised confidentiality. The provider was reliant on prison officers to escort patients to collect their medicines between the administration times of 8am and 10.30am; we witnessed administration continuing until midday to meet the demand. This was impacted by the volume of prisoners collecting their medicines as well as prison issues which impacted on the timely administration of medicines. The provider had escalated these concerns. Administration was completed by 2 members of nursing staff with the assistance of a health care assistant (HCA). The room was clean and tidy and contemporaneous records were being completed in line with the policy for Controlled Drugs. In-possession (IP)medicines were picked up between 3-5pm during which we were told there is only one nurse doing the administration and this can result in stressful situations. 87% of patients were in receipt of IP medicines of which 97% had a current In-possession risk assessment(IPRA) in place. Although occasionally we found that some people who were assessed as being allowed medicines in-possession were still attending the hatch for administration adding to the workload. This had previously been identified and as part of the previous action plan, a pharmacy technician had been conducting IPRA clinics.Healthcare staff treated people with dignity and respect and were very helpful and proactive at trying to resolve any issues, however this had an impact on the timeliness of medicines administration.

The system for getting repeat medicines prescribed and supplied still required further improvements. We saw that templates on the electronic system had occasionally expired leading to repeat medicines not being supplied by the pharmacy in time for either administration or for IP pick up (including critical medicines). Staff administered from stock supplies where they could, to prevent people missing their medicines. A repeat prescription policy had been developed and was recently issued to staff on 30th June 2026, and a prescription clerk is in the process of being recruited as the leadership had previously recognised that this was an area for improvement.

There were numerous blank boxes within the administration records, it is imperative that if someone does not receive their medicines for any reason, this is documented to enable oversight of the reasons for non-administration. Sometimes the reasons were not clear as to why someone had not received their medicines as they were just recorded as ‘missed’.The provider had already identified previously that 26% of missed collections were documented as ‘other/unclear’ but there had been an improvement in availability or supply issues being the reason for missed critical medicines.

When people did not attend for their medicines, we saw examples where staff followed them up and there was oversight of this process through audit. This had driven an increased demand for medication reviews, and an advanced clinical practitioner role had been recruited to help with this workload.

The Rochester medicines management committee meets fortnightly where audits, safety alerts and shared learning from incidents are reviewed. Dashboard monitoring showed a marked decrease in the number of missed doses especially of critical medicines, although it is imperative that repeat prescription templates are renewed and administration records are completed to enable this to be effective.

The provider reported an increase at the end of May/beginning of June 2026 in the number of medicines incidents being reported which allowed investigations to be completed and lessons learnt.