HMP Thameside

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• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked at 1 quality statement in this key question. We found the provider had not made sufficient progress to address the regulatory breaches found at our previous inspection.

Systems and processes had not improved sufficiently to be effective. Governance processes were weak, meetings were not always effective with clear agendas, and identified risks were not followed-up promptly and accurately. Learning from incidents was not well embedded and although there had been improvement in the recording of incidents, incidents were not consistently reported. Tasks, including clinical tasks were not processed promptly. Action was not always taken in relation to findings from audits. A turnaround team had been brought in to direct the service and improve on weaknesses identified in existing processes and/or staff following well established processes correctly. Improvements had been made to recording of data, although more work was needed.

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

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

Since the last inspection there had been several leadership changes at the service, we found governance arrangements were not well developed or embedded. The provider had recently put in a turnaround team to have oversight of operations and improve the service for patients.

A new head of healthcare had been appointed and had been in post for 6 weeks at the time of our inspection. Prior to this there had been several changes in leadership at the location. At the last inspection we found the provider had faced numerous challenges since taking over the service and governance structures and arrangement had been slow to embed. During this inspection we found minimal improvement.

Meeting structures were not fully embedded. The senior management team meetings were expected to take place each week, however, this did not happen consistently. We found there was no regular formal agenda for meetings or a system to record, monitor and follow up on agreed actions. For example, it was agreed at a meeting held in December 2024 that the staff working on the inpatient unit should ensure patients released or discharged from the unit should be removed or relocated on the patient record system. During this assessment we found this action had still not been implemented which meant that staff did not know where patients were located, this also resulted in several wasted internal and external clinical appointments. There were no staff meetings to cascade the relevant information to more junior staff. Reliance was placed on managers to disseminate the information, but the provider could not demonstrate this always happened.

The service had recently instigated two new governance meetings, one focused on patient safety incidents whilst the other had a general focus including complaints, performance data and audits. We found there was limited or inconsistent recording of both meetings, including a lack of evidence to describe the discussion and any actions or decision making.

This indicated there was a lack of clear leadership to ensure the function of the department operated as intended.

There was a lack of oversight over the management of external hospital appointments, and it was difficult to see which patients had attended their appointments and which patients needed to be rebooked.

We also identified there was no oversight of outstanding tasks. Tasks were created on the patient record system to make a request to another member of staff to either see and assess a patient, or to progress an action on behalf of a patient including booking internal or external appointments. We found there were a high number of overdue tasks, over 1000, some dating back as far as 12 months.

Audits were undertaken but were not used effectively to develop and improve the service. Audits were presented at a governance meeting but there was no discussion around the audit findings and we found staff had not taken action to address weaknesses identified as part of the audit process.

Management of risk, issues and performance

At the last inspection we found reviews of incidents took too long and there had been a delay in reporting of incidents. During this assessment we saw there had recently been an improvement in the reporting and review of incidents, however, we identified some incidents had not been reported and learning from incidents was not well embedded across the team. Learning from local incidents and audits was infrequent, although we were provided with a series of dates for learning sessions planned to take place going forward.

Information management

At the last inspection we found there were issues in collecting performance data. At this inspection significant improvements had been made, although more work was needed to ensure all data was collected so that it could be monitored effectively. For example, data on the number of complaints received, processed, and the outcomes provided for patients was not recorded consistently or accurately.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.