The Care Quality Commission
  • Prison healthcare

Archived: HMP Belmarsh and HMP Thameside (healthcare)

Western Way, Thamesmead, London, SE28 0EB (020) 8331 4400

Provided and run by:
Oxleas NHS Foundation Trust

Important: This service is now registered at a different address - see new profile
Important: This service is now registered at a different address - see new profile

All Inspections

09, 12, 15 and 19 May 2023

During a routine inspection

We carried out an announced focused inspection of healthcare services provided by Oxleas NHS Foundation Trust, remotely on 09,12,16 and 17 May 2023.

Following our joint inspection with HM Inspectorate of Prisons (HMIP) in November 2021 we found that the quality of healthcare provided by Oxleas NHS Foundation Trust at HMP Thameside required improvement. We issued a Requirement Notice in relation to Regulation 12, Safe Care and Treatment and Regulation 16, Complaints, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. In December 2022 we followed up the concerns reported in the requirement notice and found that they had not been met. We reissued the requirement notices.

The purpose of this focused inspection was to determine if the healthcare services provided were meeting the legal requirements of the Requirement Notices that we issued in November 2021 and subsequently in December 2022 and to find out if patients were receiving safe care and treatment. At this inspection we found that improvements had been made and that concerns had either been fully addressed or significant improvement had been made.

We do not currently rate services provided in prisons.

At this inspection we found:

  • Systems and processes to administer medicines for patients had improved. Patients who had missed doses of medicines were followed up and either subsequently received their prescribed medication or there was adequate justification why they were missed. We found the systems for managing medicines reconciliation had improved, although due to staffing shortages this did not happen consistently. Quality control checks for the blood glucose monitor were completed regularly, although when results were out of range, staff did not escalate this issue.
  • Complaints were responded to consistently. Staff had responded to the complaints in full or ensured that concerns raised were investigated and acted on. Staff informed the patient how to escalate concerns if they remained dissatisfied with the response. However, we noted that there was no process in place to respond to complainants who had been transferred or released.

The areas where the provider should make improvements are:

  • The provider should ensure that medicines reconciliation checks are undertaken for all patients in a timely manner and that when blood glucose quality control check results are out of range, this is escalated in line with policy.
  • The provider should ensure there is a process in place to respond to complainants who have been released or transferred.

29 December 2022

During an inspection looking at part of the service

We carried out an announced focused inspection of healthcare services provided by Oxleas NHS Foundation Trust, remotely on 20 December 2022 and on-site 29 December 2022.

Following our last joint inspection with HM Inspectorate of Prisons (HMIP) in November 2021 we found that the quality of healthcare provided by Oxleas NHS Foundation Trust at location HMP Thameside required improvement. We issued a Requirement Notice in relation to Regulation 12, Safe Care and Treatment and Regulation 16, Complaints, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The purpose of this focused inspection was to determine if the healthcare services provided were meeting the legal requirements of the Requirement Notices that we issued in November 2021and to find out if patients were receiving safe care and treatment. At this inspection we found that some improvements had been made, however the provider continued to be in breach of the regulations and more work was needed.

We do not currently rate services provided in prisons.

At this inspection we found:

  • Systems and processes to administer medicines for patients were not always safe. Some patients had missed doses of medicines, some of which were critical and systems for managing medicines reconciliation were not effective.
  • Complaints were not responded to consistently. Staff had not always responded to the complaint in full or ensured that concerns raised were investigated and acted on. Staff did not always inform the patient how to escalate concerns if they remained dissatisfied with the response.

The areas where the provider must make improvements as they are in breach of regulations are:

  • The provider must ensure that patients receive their medicines as prescribed.
  • The provider must ensure complaints are fully investigated and responded to and that proportionate action is taken in all cases. The provider must ensure that complainants are informed of how to escalate the complaint in accordance with local guidelines.

The areas where the provider should make improvements are:

  • The provider should review the storage of emergency equipment bags and ensure that medical devices are suitable for use.
  • The provider should ensure that local and regional complaint guidelines are consistent.

01 May to 02 May 2019

During an inspection looking at part of the service

We carried out an announced focused inspection of healthcare services provided by Oxleas NHS Foundation Trust at HMP Thameside on 1 and 2 May 2019.

Following our last focused inspection in August 2018, we found that the quality of healthcare provided by the trust at this location required improvement. We issued a Requirement Notice in relation to Regulation 17, Good governance, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The purpose of this focused inspection was to determine if the healthcare services provided by the trust were meeting the legal requirements of the Requirement Notices that we issued in December 2018 and to find out if patients were receiving safe care and treatment. At this inspection we found that improvements had been made and the provider was not found to be in breach of the regulations.

We do not currently rate services provided in prisons.

At this inspection we found that:

  • Systems for monitoring storage temperatures of medicines were now effective.
  • Systems for checking items stored in the main emergency bags were now effective, although some out of date items were found in the small grab bags.
  • Oversight and management of patients with long-term health conditions had mostly improved, including the development of care planning.
  • Oversight and management of tasks on the SystmOne electronic clinical recording system had improved.

The areas where the provider should make improvements are:

  • The provider should ensure that patients with diagnosed long-term health conditions such as epilepsy and diabetes have a personalised care plan in place.
  • The provider should implement a system to routinely check items in the small grab bags.

16 Aug to 17 Aug 2018

During an inspection looking at part of the service

The five key questions we ask and what we found

Are services safe?

We did not inspect the safe domain in full at this inspection. We inspected only those aspects mentioned in the Requirement Notices issued in September 2017.

At this focused inspection, we found that the systems for monitoring storage temperatures of medicines were not always effective in ensuring their suitability for use, and systems for checking emergency bags were not fully effective.

Are services effective?

We did not inspect the effective domain in full at this inspection. We inspected only those aspects mentioned in the Requirement Notices issued in September 2017.

At this focused inspection, we found that most patients with long-term conditions and those requiring wound care did not have personalised care plans in place. This meant that information needed to help staff plan and deliver care and treatment was not readily available. There was no clear system to monitor patients with long-term conditions to ensure the care and treatment they received met their needs.

Are services caring?

We did not inspect the caring domain at this inspection.

Are services responsive?

We did not inspect the responsive domain in full at this inspection. We inspected only those aspects mentioned in the Requirement Notices issued in September 2017.

At this focused inspection, we found that access to GP services was sufficient, and healthcare staff dealt with applications for treatment promptly. While outstanding tasks (prompts for staff to take action regarding a patient) for the GP had reduced, the overall number of unactioned tasks had increased significantly and there was no effective process in place to manage this.

Are services well-led?

We did not inspect the well-led domain in full at this inspection. We inspected only those aspects mentioned in the Requirement Notices issued in September 2017.

At this focused inspection we found that some systems did not effectively assess, monitor and improve the quality and safety of the service. We saw evidence of the provider using audits feedback to improve service delivery.

Key findings

Our key findings were as follows:

  • Systems for monitoring storage temperatures of medicines were not fully effective.
  • Systems for checking items stored in emergency bags were not fully effective.
  • Oversight and management of patients with long-term conditions required improvement, including improved care planning.
  • Oversight and management of unactioned tasks on the SystmOne electronic clinical recording system required improvement.
  • Access to GP services was sufficient.
  • Oversight and management of healthcare applications had improved.
  • The provider had started to use audits to improve service delivery.

Action the service MUST take to improve:

Oxleas NHS Foundation Trust must ensure that governance systems and processes assess, monitor and improve the quality and safety of services.