HMP Lowdham Grange

On this page

• 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 did not inspect the well-led key question in full as part of this focused inspection.

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.

At our last inspection we found that there was no oversight or quality assurance of complaints in place, and the system for reporting, logging and investigating a complaint was unclear with staff managing complaints in different ways. The management of patient complaints was poor, patients did not always receive a timely response to their complaint, and there was no local oversight of complaints about the service to identify themes and learning.

At this inspection we found that a process to manage patient complaints had been implemented and there was improved oversight at a local level of the complaints received. We found that:

• Complaints were logged on an electronic database which was accessible to managers and shared with the trust Patient Advice and Liaison Service (PALS) to monitor timeliness of responses and investigations.

• Complaints were allocated to senior clinical staff to investigate where appropriate.

• A monthly report was produced by the trust PALS and patient safety team to highlight themes and trends from complaints.

• Feedback from complaints was shared with staff during daily handover meetings.

Despite some improvements in the management of complaints, we found that there were some ongoing concerns. We found that:

• In the 3 months prior to our inspection only 40% of complaints had been responded to in line with the provider’s policy. This was due to staff absences.

• There was no quality assurance process for the responses to concerns from patients at a local level.

• Incoming complaints were date stamped on the day they were logged on the complaints database instead of the day they were received by healthcare. This could lead to inaccurate data for timeliness of responses.

• There were no regular full staff meetings at a local level to share themes and trends from complaints with the full staff team.

Managers were aware of the ongoing concerns regarding the management of complaints, and this was recorded on the service risk register with plans in place to further improve the management of patient complaints.

At our last inspection we found that there was a backlog since April 2023 of 330 incident reports which had not been reviewed. There was no quality assurance or oversight of incident investigations and managers had not identified that incidents were not being reviewed until 2 weeks prior to our last inspection. Local managers were unable to access the incident tracker which prevented them identifying themes and learning, and not all staff had access to the provider's incident reporting system to report incidents.

At this inspection we found that incidents were reviewed and investigated in a timely manner and there was improved oversight of incidents at the service. We found that:

• All staff had access to the provider’s incident reporting system to log an incident.

• Managers had access to the incident reporting system to review incidents and record details of investigations.

• There were no overdue incident investigations in the 3 months prior to our inspection.

• The area manager quality assured incident investigations and monitored the timeliness of these.

At our last inspection we found that the risk register did not include all known risks to the service including the poor complaints system. We also found that managers had failed to identify and address the risk around the patient application system, and managers were not aware of how to escalate risks to senior managers or to the trust board.

At this inspection we found that the risk register for the service had been recently reviewed and updated, and managers had a clear understanding of how to escalate ongoing risks to the service. We found that:

• The head of healthcare and area manager had a clear understanding of the risks to the service, and these were clearly documented on the risk register with regular reviews evidenced.

• Details of the risk register were monitored by the provider’s patient safety lead who also had oversight of current risks and action required to mitigate these.

• Risks were discussed in a monthly quality governance meeting to raise awareness and review any action required to mitigate these risks.

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.