This report was on an unannounced inspection of HMP Forest Bank between 13,14,20–24 May 2019, and was published in September 2019.
General Points of Interest:
The levels of self-harm had increased significantly since the previous inspection and were concerning. There had been 734 incidents of self-harm by 177 prisoners during the previous six months.
As part of the survey, 63% of prisoners said that they had mental health issues.
51% of prison officers had less than 2 years’ experience, 37% had under 12 months.
In the survey, 61% of prisoners said it was easy to get illicit drugs at the prison and 26% said that they had developed a drug problem while at Forest Bank against the comparator of 16%.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||4||4|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
The complaints system was now confidential with work in progress to differentiate complaints more clearly from applications and concerns. Most patients expressed dissatisfaction with medication issues. Written responses to complaints were courteous, timely and apologetic where necessary. Patients could influence health services development through regular user surveys and the monthly consultative meeting.
Clinical leadership (other than in in-patients) was good with experienced staff providing primary care, along with 24-hour nursing cover. Health staff mandatory and further training was very good, and now included safeguarding of adults.
Annual appraisal and managerial supervision arrangements were in place and staff generally felt supported. Clinical supervision was voluntary and not all primary care staff took advantage of it.
Most clinics were held in the health centre where the range of clinical activities had outgrown the space available. The waiting area was well supervised and contained relevant health promotion materials. Patients spent less time there than in 2016. The temporary waiting room facilities for vulnerable prisoners were sparse and unwelcoming.
SystmOne records that we sampled were informative and subject to clinical audit. Audits demonstrated good compliance with information governance standards along with an active programme of other clinical audits ensured compliance with expected standards.
There was a prison-wide approach to health promotion and the multidisciplinary action board met every two months to promote wellbeing across the prison. National health campaigns were promoted by identified staff. Health-related materials were displayed throughout the wings, health care and the gym. Supportive self-help materials were available in the library.
At time of inspection, there were no health champion peer workers, although there were advanced plans to start recruitment.
Opt-out screening and treatment of blood-borne viruses were very effective, supported by good links with a local specialist service. There was good access to age-appropriate immunisations and vaccinations, national screening campaigns, such as abdominal aortic aneurysm and bowel cancer, and smoking cessation.
Initial health screening was undertaken promptly by a registered nurse. Attendance rates at secondary health assessments had improved significantly, ensuring good support during prisoners’ early days. Staff made appropriate referrals to other clinicians from these initial assessments.
The appointments system was effective, although appointment slips were handed to officers without a sealed envelope, which compromised confidentiality.
At the time of the inspection, 355 patients had long-term conditions such as asthma, diabetes or epilepsy and were regularly reviewed by competent staff, with care plans and evidence-based practices.
GP services were available each weekday and Saturdays, and out-of-hours cover had been introduced but was rarely used. Patients had good access to urgent same-day GP appointments and non-urgent appointments within 10 days, which was reasonable.
The did-not-attend (DNA) rate was 16% for the GP, which was an improvement. While DNA rates for some other clinics remained high, innovative ways to engage patients and reduce DNAs had been introduced, such as a clinic in the gym. The range of specialist clinics was good and included physiotherapy, ophthalmics and podiatry, with short waiting lists.
External health care appointments were well managed by an administrator, with clinical input where required. Few were cancelled for security reasons. Telemedicine equipment was installed during the inspection to enable specialist consultations without leaving the prison.
All patients were reviewed before release by a nurse and given any ordered medication to take home, along with advice on accessing community health services and a care summary record. While most released and transferred prisoners left with their required medication, recording of this was inaccurate and ineffective, despite recent measures implemented to monitor and improve compliance.
The inpatient unit remained a poor environment with 19 beds in single and double cells, and one four-bed bay. The unit was stark and sometimes excessively noisy. Bed occupancy ran at about 63%. One bay was in use as a temporary waiting room for vulnerable prisoners attending out-patients, which was not ideal. Prison and health staff were not familiar with the admission criteria, though these were updated and re-issued at the time of the inspection. Between the well-attended weekly multidisciplinary care team meetings, admissions were made to the unit for non-clinical reasons, which was not appropriate.
In the survey, 63% of prisoners said that they had mental health problems. While only 32% said they received help with these problems, inspectors found that mental health provision had improved since the last inspection, despite high demand for support.
The integrated mental health team was well staffed and provided daily support to prisoners, including attendance at ACCT reviews. Three of the registered mental health nurses regularly covered general primary care duties, which affected their capacity to deliver mental health care.
New MH referrals and complex cases were reviewed at an effective weekly team meeting and single point referral meeting with multidisciplinary input.
The waiting list for initial triage appointments had halved since our last inspection. Prisoners could wait up to three weeks for an initial triage appointment, which was too long. Attendance at mental health appointments was good, and staff appropriately followed up those who did not attend.
The in-reach team provided good support to 58 men with more severe mental health conditions using the care programme approach. There was prompt access to the service and prisoners were reviewed regularly, including physical health checks and psychiatric consultations. Clinical records that we sampled contained evidence of responsive and personal care planning and regular risk assessment.
60% of prison officers had received mental health awareness training, which was an improvement since 2016. The psychological wellbeing practitioner had recently started delivering a more detailed training programme for prison staff.
In the survey, 49% of respondents said they had a drug problem on arrival at the prison against the comparator of 34%. At the time of inspection, 402 prisoners were engaged with the Integrated Substance Misuse Services (ISMS) work focused on recovery.
New ISMS referrals were seen within five days and there were robust systems for urgent referrals to be seen promptly. All prisoners arriving in reception were seen by an ISMS worker for assessment. They could see a clinical prescriber if necessary and were given harm reduction advice and materials as appropriate.
Effective multi-agency working between the ISMS, health care and the prison was evident with recorded monthly meetings to share information and intelligence. There was a drug strategy but no action plan (see paragraph 1.53). The prison programme manager was co- located with ISMS team managers which facilitated effective communications.
The governance of the ISMS was very good, compliance with staff mandatory training was excellent, and clinical and managerial supervision was well embedded. Staff we spoke to valued weekly group supervision sessions and felt supported in their roles. A recent prisoner consultation (February 2019) had informed service delivery.
At time of inspection, 192 prisoners were in receipt of methadone opiate substitution therapy (OST) and four were receiving rapid release buprenorphine. The majority (85%) were receiving maintenance doses, which was clinically appropriate. Prescribing was flexible and medicines were administered from G/H wing. We observed a noisy and poorly controlled medication queue, but the risks were addressed immediately when we raised concerns.
About 87% of patients had medicines in possession (50% in 2016). The policy was applied and risk assessments were completed and repeated as necessary. Patients received in-possession medications in health care. There was still no lockable storage for patients to store medicines in their cells safely.
The small number of tradeable medications being prescribed was impressive, reducing the risks of bullying. However, many prisoners complained that they were not receiving medicines that their GPs prescribed in the community.
Nurses administered medicines up to three times a day at appropriate times. The medicines queue at the administration room on the A-F hub was congested but well supervised. Patients sometimes experienced delays in receiving their medicines, causing gaps in their treatment, but many did not request repeat prescriptions despite reminders to do so.
As part of the survey, 30% of prisoners rated the overall quality of the health services as being either very good or quite good.
Recommendations: Health, Well-Being and Social Care:
- Appointment slips for health appointments should be distributed in a way that preserves the patient’s confidential medical status.
- All prisoners should be released or transferred with their required medication, and this process should be recorded accurately and regularly monitored.
- Patients requiring mental health inpatient care should be transferred within the national guidance timeframe.
Good Practice: Health, Well-Being and Social Care:
- The novel introduction of a nurse-led clinic in the gym enabled patients who preferred to attend the gym to access health care. Long-term condition monitoring was improved by arranging health checks in the gym.
- Integrated substance misuse services (ISMS) workers were aligned with identified community services which created a ‘virtual’ through-the-gate team ensuring seamless, collaborative release planning and aftercare.
CQC Requirement Notices Issued: