This report was on an unannounced inspection of HMP Bristol between 20–21 May and 3–7 June 2019, and was published in August 2019.
“Bristol may not have reached the extreme lack of order and crisis seen in some other prisons and this report acknowledges some developments and some improvements, but many initiatives were poorly coordinated, applied inconsistently or not well embedded.” – Peter Clarke
General Points of Interest:
More than 10% of the population were subject to Assessment, Care in Custody and Teamwork (ACCT) case management procedures which is partly attributed to health services staff being instructed to open an ACCT document routinely whenever a prisoner had a history of self-harm, without applying their clinical judgement first.
62% of prison officers were within their first two years of service.
19% of prisoners said that they had developed a drug problem at the prison.
The safer custody hotline was not checked by staff. During the inspection, staff retrieved 21 voicemail messages dating back over two weeks. Three of the prisoners concerned had already been released from the establishment.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||2||2|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
Patient engagement was newly established via prison-led forums.
The incident reporting system was good, had clinical oversight and demonstrated that learning was occurring.
Training was good and staff received monthly management supervision and quarterly clinical supervision. Clinical records appropriately captured patient contacts and clinical decisions, and were audited to ensure compliance with professional standards.
An effective governor-led, prison-wide approach to health promotion was established, with well-being materials displayed throughout the prison.
There was no access to prescribed smoking cessation, leading to too much reliance on prisoners buying their own nicotine substitutes.
Initial health screening was undertaken promptly by a registered nurse in reception, with appropriate onward referral to other clinicians. Secondary screening was routinely offered but take-up was variable. Health practitioners were advised always to open an ACCT if a prisoner mentioned any historical risk of self- harm, irrespective of when this had occurred and without regard for its severity and context, which was deemed by inspectors as being disproportionate.
Prisoners made appointments by approaching health care professionals on the wings, which triggered an initial triage appointment with a nurse. The absence of a written confidential request system could have inhibited prisoners from seeking help, although nurse-led triage on wing hubs worked well.
Besides the poor access for patients with mobility issues, escorting and regime issues also sometimes delayed general access to the health centre. The excellent ground-floor urgent care facility was rarely used owing to a shortage of prison staff.
Inspectors observed positive engagement with prisoners, and some very proactive outreach by senior clinicians to ensure that patients who were unable to attend appointments were seen on the wings.
The Integrated Mental Health Service included a crisis team, therapies team, neurodevelopmental nurse, social prescriber, non-medical prescriber, clinical psychologist and psychiatry input. The care programme approach (CPA) was used to manage secondary mental health needs.
The therapies team saw all new arrivals, to inform them of services and provide a range of literature, including in-cell distraction packs. Overall, a dedicated and passionate team offered a wide range of treatments, including psycho-education, facilitated self-help, psychological therapies in both a one-to-one and group setting, crisis support and specialist secondary care.
The crisis team operated seven days a week, from 7am to 8pm, and the therapies team operated Monday to Friday, from 9am to 5pm. Demand for mental health services was high, with 67% of prisoners in the survey saying that they had a mental health problem. There was an open referral system, and triage assessments were completed in a timely manner.
New MH referrals and assessments were reviewed during a weekly multidisciplinary team meeting, and daily handovers took place to share concern and risk information.
The crisis team saw all 24-hour ACCT reviews and contributed to the multidisciplinary support offered to prisoners who self-harmed. Working relationships with the prison were positive and staff supported the work of the segregation unit.
Integrated Substance Misuse Services had improved and were impressive. In the survey, 33% of respondents said that they had had an alcohol or drug problem on arrival at the prison, and at the time of inspection 163 (33%) were engaged with recovery-focused work.
All new prisoners were screened for alcohol and drug issues and, if necessary, saw a clinical prescriber and were referred for assessment. New referrals were usually assessed within two days.
First-rate partnership working was underpinned by a good drug strategy and relevant action plan. A governor was dedicated to health and substance misuse care, and oversaw implementation of the action plan.
Substance misuse services staff were competent and compliant with mandatory training requirements, and clinical and managerial supervision was well embedded. Staff spoke of feeling valued and supported.
Naloxone was provided to prisoners being released, as indicated. ʻThrough-the-gateʼ work with community drugs services, housing and homelessness charities.
An in-house pharmacy supplied medicines. Not in-possession (NIP) medicine was administered safely and efficiently from the wings, three times a day, by pharmacy technicians, with night-time administration facilitated by nurses. A dedicated wing-based medicine management team provided consistent support to patients. NIP medication was mostly administered from stock, which limited the additional checks that individually labelled use would have provided. Officer supervision of medicines queues was inconsistent, which meant that there were opportunities for diversion, and privacy was difficult to achieve.
In-possession (IP) medicine arrangements were effective; risk assessments were undertaken and regularly reviewed. Cell checks were conducted but the lack of lockable cupboards in shared cells was a factor determining that only around 13% of patients received their medicines IP.
The transport of medicines was secure and incorporated the use of padlocked bags. There was insufficient storage space on some wing treatment rooms.
There was a full range of standard operating policies in place. A comprehensive range of medicines was available without prescription via patient group directions (PGD’s), and a minor ailments policy.
There was the potential for more pharmacy-led clinics, including smoking cessation. All prescriptions were clinically screened by the pharmacy, and some joint medication reviews were carried out between the pharmacist and the prescriber.
Espranor (a freeze-dried wafer which contains buprenorphine) was supplied to prisoners prescribed buprenorphine. The benefits being that this dissolves directly on the tongue, reducing the time spent in administration and the risk of diversion.
There were monthly clinical governance meetings, and good input from the pharmacy team into drugs and therapeutics committee meetings.
As part of the survey, 29% 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:
- All clinical rooms should meet required infection control standards, with adequate storage and space to provide effective and accessible health services. (Repeated recommendation)
- A rolling programme of mental health awareness training should be provided for all custody staff. (Repeated recommendation)
- All medicine queues should be supervised adequately, to protect patient confidentiality and prevent bullying and diversion.
Good Practice: Health, Well-Being and Social Care:
- Through-the-gate work with community drugs services, housing and homelessness charities, and Bristol Council services provided prisoners with an unusually wide range of supported living options.
- A dedicated wing-based medicine management team carried out most medicine administration, improving the management of stock, the ordering of prescriptions and the provision of consistent support to patients.
- Espranor was supplied to prisoners prescribed buprenorphine; this dissolves on the tongue, reducing the time spent in administration and the risk of diversion.
CQC Requirement Notices Issued: