HMP Peterborough Prison

On this page

• 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 1 quality statement for this key question. We found the service had made sufficient progress to address the regulatory breaches found at our previous assessment. Processes for identifying and following up on missed medicines had improved, and clinical records clearly and accurately documented depot administration.

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

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

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 judgement for Safe and effective staffing is based on the latest evidence we assessed for the Safe key question.

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

At our last assessment, we found ineffective processes for maintaining oversight of patients who did not receive their medicines.

At this assessment, we found improvements. Staff worked collaboratively across all teams to identify and follow up on patients who had missed their medicines. The pharmacy team had worked with healthcare leaders to review the missed medicines protocol and created a flowchart that outlined the actions to take when a patient missed their medication.

When a missed dose was identified, staff assessed the severity and urgency of the medicine and took appropriate follow-up action, based on the individual circumstances and needs of the patient.

Assurance processes flagged patients who had missed three or more doses and escalated these cases for discussion and action at multidisciplinary meetings. Both the pharmacy and healthcare team generated regular reports from the clinical system to identify such patients. We found these processes could be improved by streamlining workflows and improving coordination between teams. Additionally, the flowchart could be improved by including these steps. The provider told us they would review their assurance process and update the flowchart.

We reviewed patient records for those who had missed medicine, and we attended 2 ‘huddles’ (one for female patients and one for male patients), which was a daily multi-disciplinary meeting to discuss patients and any updates. We found staff were following the protocol and saw evidence that the reason for the medicine being missed was recorded, and appropriate action was taken.

At our last assessment, we identified inconsistencies in clinical records for depot injections (a depot injection is a slow-release form of medication, which can be used to treat mental health conditions).

At this assessment, we found there had been significant improvement. Record-keeping by all departments had strengthened, and despite staffing challenges, the pharmacy team were working proactively to make sure patients received their medicine. They had reviewed processes and introduced a new system for holding medicines in stock, which resolved previous issues of medicines being unavailable.

The pharmacy team maintained an accurate register of patients receiving depot injections. They ran regular reports to confirm patients were booked in, and medicines were organised in advance of the due date. Once per week, the pharmacy visited patients to administer the dose if any patient did not attend or was not able to attend.

We found the administration of the medicine was consistently and accurately recorded in the patient records we reviewed. In one case, a patient missed their dose because they were in hospital, and this was clearly documented.