HMP Five Wells

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

During this inspection we looked at 3 quality statements. During this inspection we reviewed the breaches from the last inspection, and we found that the provider had addressed the previous breaches and were now compliant with relevant regulations. At this inspection we found lessons learned from incidents, audits and patient complaints were shared with staff, adequate storage space was available to securely store patient medicines, governance meetings were held regularly to ensure oversight of the service, and staff training, appraisal and supervision compliance had improved, and staff felt supported by managers.

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

At our last inspection we found that there had been no clinical governance meetings since service delivery commenced which meant that learning from audits, incidents and complaints had not been routinely shared with staff. At this inspection, we found that meetings had taken place regularly since our last inspection and were scheduled on a bi-monthly basis. Clinical governance meetings had been carried out in March, May, July, September and October 2024. Meeting minutes reviewed for these meetings evidenced discussion regarding recent audit findings, and themes from incidents and complaints. This meant that lessons learned were now routinely reviewed and shared with the wider staff team.

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 there was no clinical oversight of substance misuse services. An agency non-medical prescriber and on-site GPs supported substance misuse prescribing, but the lack of a substantive specialist substance misuse prescriber had resulted in a backlog of patients awaiting 13-week prescribing reviews for opiate substitution therapy. At the time of the inspection, 25 patients out of 105 were overdue reviews due to a lack of staff. At this inspection we found there was improved oversight of clinical substance misuse services. We found that a substantive non-medical prescriber had been recruited and was due to take up post imminently. The non-medical prescribing hours for the service had been increased from 1 to 3 days per week to meet the demands of the service. A newly recruited Band 7 nurse now had responsibility for oversight of the substance misuse and mental health pathways. No patients were overdue a 13-week review at the time of our inspection.

At our last inspection we found staff had not received an appraisal of their professional development or completed all mandatory training in line with the provider’s policy. We also found that staff did not receive regular supervision to support them in their roles. At this inspection we found staff appraisal and mandatory training completion data had improved, and staff felt more supported in their roles. We found the mandatory training completion rate for the full staff team at the time of our inspection was 93%. 60% of staff had received an appraisal compared to 0% at our last inspection. Outstanding appraisals had been scheduled to complete with staff in the months following this inspection in line with the provider’s timescales. Clinical and managerial supervision were offered to staff monthly. The compliance data for staff attending supervision was 79% for clinical supervision in September 2024, and 47% for managerial supervision in October 2024. Staff we spoke with during this inspection told us they felt supported by managers and were able to raise any concerns with them.

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

At our last inspection we found that there was insufficient storage for all patient medicines in the medicines’ administration room on Stanwell houseblock. This meant that patient medicines were not locked away securely. At this inspection we found that new cabinets had been installed in the medicines’ administration room on Stanwell houseblock which were securely fitted to the walls and provided adequate storage for medicines. This meant that patient medicines were now securely locked away.