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 a total of 2 quality statements from this key question. We found the provider was not providing safe care in accordance with the relevant regulations. The provider had made some improvements in relation to safe and effective staffing and medicines management.

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.

At the last inspection we found managers and leaders did not have adequate protected time to carry out their roles and responsibilities and review patient pathways. During this assessment we spoke with healthcare managers; they told us they were not undertaking clinical tasks and they had time to carry out their duties with support from the wider team. Managers felt that their integration into the teams across the male and female sides of the prison was positive and helped them to have oversight. Since the last inspection, the Trust have continued to actively recruit new staff. There were 2 new registered mental health nurses and 3 administrators due to start with adverts out for a substance misuse nurse, a mental health team lead and a nurse practitioner. At the time of this assessment there was a new psychologist in post for the mental health team, who was working to improve services for patients. They had only been in post a few weeks but were sighted on areas that needed to improve, such as clinical triage and timely assessment There was a new pharmacy manager in place, who was working hard to develop and improve the pharmacy service and the provision of medicines for patients. There was a healthcare lead for both the female side and the male side. The head of healthcare was the Trust assistant director for secured services.

At the last inspection only 22 patients on the women’s site were receiving help from the mental health team. There were long waits to be assessed, and some patients were being released before being seen. During this assessment, managers provided evidence to show that the team now supported an average of 40 patients, however, we found some patients were still waiting too long to be assessed. There were only 2 full time nursing staff and 2 ad hoc bank staff providing aspects of primary and secondary mental health care. This included a duty role, requiring them to attend patient ACCT reviews, carry out assessments and attend the prisons safer intervention meeting. Staff told us that their role was very busy and they felt pressured to get everything done. We saw that staff were working extremely hard to deliver a service, they were balancing the demands of attending meetings, the duty role, delivering clinics, care co-ordination and additional work such as delivering the perinatal pathway. It was evident that staff were stretched, covering all aspects of the mental health service, which is not sustainable.

There was a clear referrals process in place for the mental health team. Between April and September 2024 there were 206 new referrals to the mental health team. Staff held a daily meeting to discuss new referrals, prisoner transfers or those due to go to court. We observed one daily meeting and it was clear that this was a good opportunity for staff to discuss patients; however, due to staffing limitations; although discussed, referrals were simply added to the triage or assessment list. We found 45 patients were on the waiting list for a mental health assessment, with the longest wait since December 2023. The Trust confirmed that this patient had actually been seen and the data needed cleansing to give an accurate picture of waiting times. However, patients were waiting up to 28 weeks to be seen for an assessment. There was no waiting time for patients with urgent needs. There were 184 patients waiting to be seen on the mental health triage list, with one patient waiting since August 2024.This meant these patients were not yet prioritised for needing an assessment and there was no clinical review, risk management or prioritisation of need of those on the triage list. This meant there were potential unmitigated patient risks and there was a risk patients’ mental health may deteriorate before being seen.

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 there was limited oversight of the pathways for patients who may have missed medicines. The trust had a process in place where staff should record each patient that missed any critical medicines and share this within the team ‘huddle’, staff then should speak with the patient to encourage them to attend for their medication. If patients did not attend for 3 days, nursing staff were to task the prescriber to review the prescribed medicines. However, we found that staff were not following this process. We reviewed patient care records, the primary care teams huddle meeting minutes and sampled prescriptions charts and found, 10 out of 11 records did not consistently show a record of the reasons why patients did not collect their medicine and staff did not consistently discuss patients that did not attend in the huddle. We saw staff were using reasons such as; DNA, patient refused medicines and medicines not available interchangeably, meaning reporting was inaccurate. One patient was prescribed medicine but did not get his prescription until 8 days later, his records showed that the medicine was unavailable and he DNA. Staff kept a list of patients who were on critical mental health medicines such as depots and kept a log of their monthly administration date, so that they would not be missed. However, the documentation for depot injections was poor. We found one patient had been administered a depot but their records stated their medicine was unavailable. The team huddle minutes did not document that another patient had refused medicine for two weeks, another patient was not administered their depot but records showed this was administered. We saw copies of the last 6 months medicine management meetings, we identified staff reported a range of medicine incidents where staff could not find patient medicines or that it was not in stock and this was recorded as the patient not attending, which was not the case