HMP Lowdham Grange

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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 6 quality statements for this key question. We found that staffing arrangements were improving following a significant recruitment campaign, and most staff felt well supported. Safeguarding arrangements were good and there was a learning culture within the service. However, patients did not always receive a secondary health screening following arrival to the prison which went against the best practice guidelines. Medicines were generally well managed, but prison officer supervision of administration was inconsistent.

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

There was a learning culture within the service. Staff understood their responsibilities to raise concerns and felt encouraged by leaders to do so. Incidents, including deaths in custody, were reviewed appropriately and learning was used to drive improvement.

A clear process was in place for staff to report and investigate incidents on an electronic system. All incident reports were reviewed by a senior manager and allocated to a lead investigator within 72 hours. Outcomes were reviewed and staff could request feedback.

The monitoring and evaluation of clinical incidents and deaths in custody was effective with lessons learned shared with staff to enhance service delivery. Learning was shared through daily staff handover meetings and supervision sessions. One example included the replacement of manual suction equipment in emergency bags to electronic suction. This demonstrated learning from serious incidents.

A registered healthcare professional carried out an initial health screening for new arrivals to the prison. Initial screenings identified any historic or current health issues with the appropriate onward referrals made. Patients were invited to attend a secondary reception screening however data showed that in March 2026 only 38% of patients had received this, which was concerning. Managers were aware of this issue and had developed an action plan to address the low completion rate. This was a work in progress; enablement issues with the prison facilitating these appointments appeared to have been resolved and managers were now reviewing data weekly to identify why the completion rate was so low. This meant that not all patients received a comprehensive assessment of their full needs within 7 days of arrival at the prison in line with National Institute for Clinical Excellence (NICE) guidance.

Although there were no patients in receipt of a social care package at the time of our inspection, a referral pathway and memorandum of understanding was in place with the local authority to ensure referrals, assessments and care could be provided if required. The local authority lead for social care attended local delivery board meetings to maintain communication with healthcare and the prison regarding potential referrals or care packages.

The practice and performance manager had oversight of patients who did not attend (DNA) their appointments. A weekly report was produced to identify all DNAs and a message sent to those patients electronically using the prison kiosk system to encourage patients to rebook if they still required their appointment. We saw evidence of weekly DNA data being analysed to identify any trends in DNAs.

Administrative staff processed patient referrals for external hospital appointments. Routine referrals were completed within 1 day and no urgent referrals were outstanding during the inspection. Referrals were recorded on SystmOne and clinicians had oversight of waiting times using a risk rating system to ensure those with the highest clinical need were prioritised if the prison or hospital had to make any cancellations. Improved joint working with the prison had reduced the number of outstanding hospital appointments by 50% in the 9 months since the provider took over the contract at the prison. Despite this, secondary care appointments remained on the provider’s risk register due to operational challenges from the prison and community service pressure leading to potential delays in care.

Patients leaving HMP Lowdham Grange were seen by a nurse prior to discharge and received a summary of their care along with a short supply of medicines to take with them.

Safeguarding arrangements were effective; concerns were logged, tracked and overseen appropriately. There was a prison-specific safeguarding local operating procedure, and all staff we spoke with understood how to report concerns. All staff, including administrative staff, had completed level 3 safeguarding training.

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.

A significant ongoing recruitment campaign had increased staffing levels, although a high number of staff were still undergoing pre-employment checks. This was due to national delays in completion of vetting checks and was outside of the health provider’s control. Agency and bank staff continued to provide interim cover for vacancies. Once staff onboarding had taken up post, the vacancy rate was 18% which was a substantial improvement since the provider inherited the contract in July 2025.

With the support of NHS England, a 24-hour nursing provision had been reinstated to better meet the needs of the population. Additionally, a deputy head of healthcare role had been introduced to strengthen leadership and oversight of health provision. Prison leaders spoke positively of these changes and felt it improved patients’ experience.

Long-standing vacancies for permanent staff in lead roles were being addressed. A fixed term contract had been offered to cover long term sickness for one post, and a new mental health lead had joined just before our inspection. The mental health lead had quickly identified priority areas to work on with mental health staff and brought enthusiasm and energy to the service which had been well received.

Compliance with mandatory training had improved and the overall completion rate was now 86%, just over the trust’s target of 85%. Managerial and clinical supervision needed further improvement to ensure all staff received documented supervision in line with the trust’s policy, however almost all staff we spoke with during the inspection said they felt supported by managers and listened to, which was reassuring.

Managers had recognised that some staff had found it difficult transferring to the trust and had implemented certain measures to support those staff. This included a listening event for staff, a staff survey repeated every 3 months, and the implementation of regular governance meetings to improve information sharing.

The provider had an infection prevention and control (IPC) lead who had carried out an audit of the prison healthcare facilities in April 2026. The overall compliance score for this audit was 95% which was good, however there were some environmental issues requiring attention which were outside of the provider’s control, such as damaged flooring in clinical areas. The provider was liaising with the prison regarding this, and it was included on the service risk register. It was positive that the provider had funded replacement hand washing facilities in clinical areas to meet infection prevention and control standards.

During the inspection treatment rooms and clinical areas were generally clean and tidy however we observed some issues such as cleanliness of hand washing facilities in clinical rooms and some gaps in cleaning schedules. The cleanliness was addressed immediately by the provider, and weekly monitoring of cleaning schedules had recently been introduced to address gaps and was overseen by the head of healthcare.

Staff received the appropriate IPC training for their roles. The provider had appropriate arrangements for managing clinical waste, which was collected regularly by an external provider. Sharps bins were labelled and stored correctly.

An on-site pharmacist and regional pharmacy lead supported a team of pharmacy technicians and a lead technician. Plans were in place to review the pharmacy staffing model, and bank staff were utilised to cover the existing pharmacy technician vacancy. A second pharmacist was also due to take up post on completion of vetting checks.

An offsite pharmacy registered with the General Pharmaceutical Council dispensed medicines and operated separately from the on-site healthcare provider. The service used a well-stocked emergency medicines cupboard and e-prescribing to obtain time-critical medicines that could not wait for the next scheduled delivery. The healthcare team also used several patient group directions (which allow registered staff to administer certain medicines without a prescription) and followed a clear homely remedy policy to supply a wider range of medicines.

Prison officers did not consistently monitor queues at medicine hatches which increased the risk of bullying and diversion. This issue was known to the health provider and significant work with the prison was underway to provide clear expectations and job roles to officers supervising medicines administration, and coaching to prison managers. Staff used systems to record, identify, and refer patients who did not attend to collect their medicines, which was good. When transferring or releasing patients, staff provided at least seven days’ supply to maintain continuity of medicines, or they issued e-prescriptions that patients could collect from their chosen community pharmacy after release.

More than half of the population received their medicines in possession: 41% held up to 28 days’ supply, and a further 21% held up to 7 days. Staff completed prescribing and administration on the combined electronic clinical records and electronic prescribing and medicines administration system. They carried out in-possession risk assessments and medicine reconciliation within designated timescales on reception and after hospital attendance or discharge. Although patients signed compact agreements (which set out expected conduct regarding medicines), staff had not uploaded these to the electronic clinical record. Staff updated in-possession risk assessments when patients’ circumstances changed acutely; however, they did not always review them annually to ensure they remained relevant. An in-possession risk assessment clinic had recently been implemented to improve this process.

Case note tracking of prescribing and administration records identified a small number of instances where duplicate prescribing occurred, which could have allowed the same medicine to be administered twice. However, administering staff identified these duplicates, gave only one dose, and recorded the other as not administered. These instances were reported as incidents in line with the provider’s policy.

A multidisciplinary safer prescribing forum routinely reviewed and optimised patients’ use of tradable medicines, as well as outcomes from cell checks and polypharmacy. Prison officers and healthcare staff carried out cell checks to assess concordance and identify evidence of trading in medicines and other substances. However, the service did not provide regular pharmacist input and did not offer routine medicines reviews.

The pharmacy team worked closely with the wider healthcare department. Staff held daily multidisciplinary meetings to discuss patient care, and they had recently restarted local drug and therapeutics meetings.