Archived: HMP Nottingham

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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 inspected 3 quality statements for this key question. We found that incidents were under reported by staff, including concerns around staffing. Where incidents had been reported we found that they were not always reviewed within the provider’s own timescales. There was limited information that learning from incidents had been shared or embedded with the whole staff team. We found that low staffing levels remained a concern. Concerns that we found about medicines during our last inspection had been addressed.

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

At our previous inspection we found that not all risks identified during the inspection were on the service risk register.
During this inspection we found that the risk register for this location was mostly reflective of concerns.

At our previous inspection we found that the quality of incident investigations was not always sufficient; and learning and improvement not embedded in the service.

At this inspection we found continued concerns about incident reporting. The provider had failed to ensure incidents were reviewed in a timely manner. We looked at incident reports from 1 September 2024 to 24 February 2025. Of the 102 incident reports we looked at, 12 had not been reviewed by a manager within the stipulated 14-day period in the provider’s policy. One incident which had yet to be reviewed dated back to 15 September 2024. The provider took action during the inspection to review all outstanding incidents.

We found that staff were not reporting incidents that impacted on the service. For example, on the 10 February 2025, a very high number (32) of emergency code calls were made which had resulted in healthcare clinics being cancelled. This had not been recorded as an incident.

The provider had failed to ensure actions identified in the service’s risk register were being implemented. For example, the risk register stated all sub-optimal staffing levels should be recorded. Of the 102 incidents we reviewed from the 1 September 2024 to 24 February 2025, we found there had only been 1 incident report for sub-optimal staffing levels. We asked for information on staffing levels for this period; this showed 51.7% of all available shifts had not been filled by substantive, agency or bank staff. There was no evidence that these shortfalls had been recorded or escalated by staff.

We found that some initial investigation reports contained minimal information about incidents. There was limited evidence to demonstrate that learning had been shared with staff and embedded into the service.

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.

At our previous inspection we found that there was insufficient staffing to meet the patient demand for nurse triage and routine GP appointments. There was a 6-8 week wait for a nurse triage appointment. Most patients wishing to see a GP had to go to the nurse triage clinic first and then wait a further 1-2 weeks for a routine GP appointment, meaning for some patients a total wait of 2 or more months.

During this inspection we found that waiting times for a nurse triage appointment had improved however, it was 29 days which was still too long. It was no longer routine that patients had to see a nurse prior to accessing the GP. At the time of the inspection we found that 49 patients were waiting for a routine GP appointment; 4 of these patients having waited between 4-6 weeks. This meant that for some patients they could be waiting in excess of 10 weeks for a routine GP appointment.

Improvements had been implemented to ensure patients received a secondary health screen by staff within 7 days. At the time of the inspection all patients, other than one with known reason for the delay, were within said timescales for secondary screens. This helped to ensure timely identification of needs.

Staffing capacity remained a concern; from the 1 September 2024 to 24 February 2025, 51.7% of all shifts had not been filled by substantive, bank or agency staff. It was accepted by staff that we spoke with that low staffing levels were the norm. Frequently managers were having to respond to inadequate staffing levels and make decisions that impacted negatively on the regular running of the service, such as planned clinics.

At our previous inspection we found that there was no senior psychologist in post due to difficulties in recruiting. The provider had recruited to this post on two occasions with one person withdrawing. The new senior psychologist was due to start imminently.

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

At our previous inspection in May 2024, we identified concerns in the management of medicines including the crushing of Buprenorphine tablets to reduce the risk of diversion which was not in line with the provider’s policy.

At this inspection we found that concerns around Buprenorphine had been addressed. Patients had been switched to a suitable alternative which did not need to be crushed. Patients had been consulted about this and their consent obtained. However, we found that the provider had not recorded these on their electronic clinical record.

At our last inspection there was limited oversight of prescribing practices and trends due to there being minimal pharmacist input. At this inspection we found pharmacy oversight and input had greatly improved. A dedicated senior pharmacist for the locality had been introduced and was onsite at least one day a week. They worked collaboratively with the senior pharmacy technician and their team, and we saw evidence of implementation of systems to improve the service such as dedicated pharmacy intranet pages for all healthcare staff.

Oversight of prescribing trends was now in place with multi-disciplinary safer prescribing meetings taking place. We saw evidence of interventions made and how this had benefited patient outcomes. For example, we saw evidence of one patient being safely detoxed from a prescription medicine after poly pharmacy was identified during the meeting. The allocated senior pharmacist was in the process of recording this within the patient record system which would also give the ability to retrieve report data.