HMP Thameside

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 6 quality statements in this key question. The provider had not made sufficient progress to address the regulatory breaches found at our previous inspection. We

found the provider had made very recent improvements on their management of reported incidents, including to ensure they were reviewed and progressed in a timely manner. However, incidents were not consistently reported and learning from incidents was not well embedded. We found systems in place to ensure patients attended external hospital appointments and were discharged safely to other services did not work effectively.

Individual patient risk was not managed consistently well although some measures had been introduced or improved on. We found individual risk assessments for patients with mental health needs were not completed and medicines were not prescribed, administered or issued in a way which was safe for patients. We also found there had been an improvement in the number of staff appointed and adequate cover provided for most shifts, as well as an improvement in completion of mandatory training. However, staff were not all receiving regular supervision, including those new into post.

A complex care meeting took place each week and these were helpful to discuss patients with multiple or complex health conditions. A rapid assessment for patients arriving to the prison was also being trialled with the lead GP which worked well, and the provider looked to extend this to ensure GPs working each shift followed this process. Managers had improved the safeguarding process so that staff knew how to raise a concern and we saw evidence of referrals being made.

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

The provider had processes for staff to report incidents, near misses and safety events, although staff had not consistently reported incidents and learning from incidents was not fully embedded.

At the last inspection we found incidents were not promptly reported, reviewed and investigated. During this assessment we found there had been a recent drive to improve the timeliness of investigations overall, however, we identified two incidents which staff had not reported. In one case, two separate members of staff had failed to report the incident. There had been some learning from serious incidents and audits, although this was not well embedded. There was evidence of some shared learning sessions for healthcare incidents which had occurred across the London prison estate, including short sessions to discuss local learning from audits and incidents, although these were not well established. Local sessions had taken place in November 2024 and not again until the week prior to inspection in February 2025. Staff we spoke with had little knowledge of lessons learned with the exception of the very recent sessions.

At this inspection, we found the service did not work well with people and health system partners to establish and maintain safe systems of care. They did not manage or monitor people’s safety. They did not make sure there was continuity of care, including when people moved between different services.

Primary Care

Patients did not always receive safe care and treatment. From our review of our patient records we found not all patients received appropriate treatment to meet their health needs. For example, in relation to management of patient wounds, we found some patients had not had their wounds properly assessed and treated. We identified patients with long-term conditions were not receiving the expected standard of treatment to meet their needs safely. We also found that patients identified through the reception process as requiring assessment and potential treatment to manage their condition were not provided with this promptly. A safe system was not in place to ensure results for patients’ diagnostic tests were followed up. We found an example where a sample had been sent to the laboratory for testing but not returned; which had not been followed up by staff.

External hospital appointments

Patients who required appointments at external hospitals for assessment, diagnostic and/or treatment were not safely managed. The provider maintained a spreadsheet to record patients who required an external hospital appointment. Referrals made by the GP were tasked to the administrator to arrange and add to the spreadsheet. We found the spreadsheet was not completed consistently with details of appointments or whether these had been attended or not. The patient record system was difficult to follow, with information being recorded in different locations rather than adopting a consistent approach. This meant it took an unnecessary amount of time to locate information to confirm whether patients had attended their appointments or not and may be difficult for temporary staff to follow. We found examples where patients had not attended appointments due to a variety of reasons and appointments were not consistently rescheduled promptly including for treatment sessions. This may impact on the health and wellbeing of the patients if they do not receive the requested assessment or treatment from a hospital clinician.

Discharge

Systems and processes were not suitable to manage patients transferred to other services safely. The patient record system was not consistently used effectively to record details about the care and treatment provided to patients to onward services. Not all patients who needed one had a clear discharge summary or discharge letter on file. This meant that the receiving service may have insufficient information about the patients’ care needs in order to provide continuity of care.

The service worked well with people and healthcare partners to fully understand what being safe meant to them and the best way to achieve that. They had a clear focus on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. They shared concerns quickly and appropriately.

During this assessment staff we spoke with understood the safeguarding process as well as the names of key staff they could discuss this with should they be unclear about whether a safeguarding referral was needed. We found most staff had completed safeguarding training appropriate to their role. Although some staff were due to complete training, we were assured that several face-to-face safeguarding training sessions were being held in February and March 2025 and that all staff who were overdue their training were booked to attend.

We saw some good evidence in patient records of safeguarding referrals being made as well as use of the ‘Call Phil’ system (Call Phil is a system operated by the provider to allow families and professionals to share information they have about prisoners at risk, the purpose being to enhance patient safety).

The service did not consistently work well with people to understand and manage risks. They did not always provide care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Staff had not completed risk assessments for patients with identified mental health needs. We reviewed a sample of mental health patient records and found that staff had not identified patient risk factors to their wellbeing or how they could be managed. This meant patients’ risks and triggers were not considered or managed effectively and patients may not receive safe care and treatment appropriate for their mental health needs.

Patients with identified complex care needs were discussed with the multi-disciplinary team to improve oversight of patients who had significant or complex needs.

At the last inspection the lead GP had established a Multi Professional Complex Case (MPCCC) meeting which took place each week. The meeting allowed the multidisciplinary team to meet and discuss patients who had been identified as having complex healthcare needs. However this was not well attended. During this

assessment we found the meetings were attended and well run. The meetings gave staff the opportunity to make others aware of patients who may require support from more than one team, or to discuss patients and seek advice from the team on how to proceed with care or any complications which had arisen. A record summary was documented for each patient and their individual patient record was also updated with details of actions agreed at the meeting.

Rapid assessment of patients arriving at HMP Thameside was taking place for some patients to ensure high risk patients were assessed and treated promptly. A new process was being trialled in reception by the lead GP. The lead GP undertook a brief rapid assessment of patients on arrival to the prison. This aimed to identify patients who were high risk, either due to complex health conditions or those withdrawing from substances who may require prompt treatment. The process worked well when the lead GP was on shift and the provider was looking to roll this out so that all GPs followed the same process which was a positive step.

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

At this inspection, we found there were sufficient numbers of suitably qualified staff to provide cover across the site, however, staff had not received adequate supervision.

At the last inspection there were a number of vacancies being filled by agency staff with some gaps in the rotas. The service had several vacancies which spanned across all

healthcare services. During this assessment we found that most vacancies had been filled and a transformation team had also been appointed to improve the safety of the

service for patients. The team was expected to be on site for approximately 6 months, which could be extended if required. A permanent head of healthcare took up position 6 weeks prior to the inspection, and over the previous 18 months, several temporary cover arrangements had been in place. Most vacant staff positions had been recruited to and from review of the rota the majority of gaps had been filled.

At the last inspection we found managers and leads had not provided staff with regular 1:1 supervision, however we were informed that several group supervisions had been held. We were informed that 1:1 supervision would be provided going forward. During this assessment staff told us they felt supported by managers. However, we found staff had not received regular supervision including those who were new to the service and undergoing their probationary period. This meant staff did not always have the opportunity to discuss their performance with managers.

At the last inspection we found staff had completed 37% of their mandatory training. During this assessment we found staff had completed 82% of their mandatory training, however, not all staff had completed safeguarding and life support training. We were assured that all staff were booked to complete these training sessions in February and March 2025 and the delays were due to course availability as well as high turnover of staff in the previous 12 months.

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

At this inspection, we found the service did not always make sure that medicines and treatments were safe and met people’s needs, patients frequently missed medicines due to delays in the ordering process or unavailability of staff.

Staff did not consistently follow procedures to ensure they prescribed and administered all medicines safely. At the last inspection we identified a small number of patients who had not been prescribed and/or administered their medicines in accordance with their diagnoses. During this assessment we reviewed a sample of patient records and found patients had not always been either prescribed or administered their medicines correctly and the reason for non-administration was not consistently recorded. This meant that patients did not always receive them as prescribed, including high-risk medicines and those for patients with long term conditions such as diabetes. All of the patients we spoke with informed us they had had issues with receiving their medicines whilst at HMP Thameside. Patients told us they either had not received their medicines at all, or there had been gaps in receiving their medicines.

Patient agreements and assessments were not always in place or reviewed regularly. From our review of patient records, we found some patients did not have a completed compact agreement in place. (A compact agreement aims to support patients in self-administering their medicines as well as to explain what will happen if the patient misuses their medicines). We also identified a delay in reviewing and updating the medicines in-possession status for one patient who had been placed on an Assessment, Care in Custody and Teamwork plan (ACCT) (An ACCT is the care planning process for prisoners identified as being at risk of suicide or self-harm). This meant there was an increased risk they may not take their medicines as prescribed.

Medicines were stored safely. Medicines both within pharmacy as well as medicines administration hatches on each of the wings were stored in a locked room and relevant controlled drugs storage protocols were followed. Patients who were in-possession of their own medicines had a suitable lockable cabinet either in their cell or on the wings to store their medicines.