This report was on an unannounced inspection of HMP Hewell between 03–14 June 2019, and was published in September 2019.
“The award of our lowest grade of ‘poor’ for safety was not a consequence so much of the actual level of violence, but more of a reflection of a range of failures to provide an environment in which prisoners could feel safe, where victims of violence would be supported, where perpetrators would be challenged and poor behaviour would lead to consistent and effective sanctions.” – Peter Clarke
General Points of Interest:
Adjudications had risen significantly from 1,584 in the 6 months before the previous inspection to 2,222 for the same period at this inspection. At the time of the inspection there were 382 adjudications that had been adjourned for up to 6 months. In addition, a further 526 were dismissed or not proceeded with in the previous 6 months.
Use of force on the closed site has increased from 178 incidents at the previous inspection to 497 in the previous 6 months. Governance of use of force incidents was weak and there was too much missing paperwork, and at the time of the inspection there were 350 missing use of force documents.
Self-harm incidents at the closed site had increased from 209 in the 6 months before the previous inspection to 350 in the same period this time. The number of ACCT documents opened had also increased from 517 in the 6 months before the previous inspection to 533 in the same period before the current one. The number of open ACCTs during the inspection was high with over 60 prisoners, 7% of the population, receiving at least hourly observational checks by staff.
Since the last inspection in August 2016 there had been 4 drug-related deaths, 2 self-inflicted deaths and 1 manslaughter on the closed site. There had been no deaths in custody on the open site.
Healthy Prison Outcomes (HMP Hewell Closed Site):
|Rehabilitation & Release Planning||3||2|
Healthy Prison Outcomes (HMP Hewell Open Site):
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|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
Prisoner council meetings had restarted one week before the inspection, the patient forum had recently recommenced, and patient feedback was gathered and analysed following health appointments.
Staff supervision was not provided in line with the health providers policies. There was no clinical supervision for staff.
Health complaints were managed well with the recent introduction of quality assurance, but face-to-face resolution was limited.
The health care department was a learning environment for nursing students and trainee paramedics from Worcester and Staffordshire universities.
Infection prevention and control had improved since the last visit. Most clinical rooms had cleaning schedules, but these were not always consistent in high-use rooms and some lacked prison contract cleaning. Although there were clinical audits continuous improvements remained outstanding.
Health and well-being information was available throughout the prison, and monthly national health campaigns were widely advertised and followed. There were robust systems and policies to prevent and manage communicable diseases.
9 prisoner health care ‘champions’ were supporting health care staff in the delivery of well-being advice and management. Those inspectors spoke to felt valued and well supported in their role, and received appropriate training.
The well-led and skilled primary care team offered an improved service since the last inspection, with shorter waiting times for appointments with nurses and GPs. There was good practice in the management of the very high levels of blood-borne viruses.
All new arrivals received a comprehensive initial health screening by a registered nurse, who reviewed risks and made onward referrals. A GP or nurse prescriber was available during the evening for complex cases, although late arrivals often missed out on this provision, causing prescribing delays. An additional nurse had been deployed to help screen new arrivals, but only 24% of newly arrived prisoners received secondary health screening. Secondary screenings were being cancelled due to lack of rooms.
External hospital appointments were managed well. Although some appointments had been cancelled to facilitate the large number of emergency admissions, the number that had breached the NHS 18-week rule for non-urgent consultant treatment had been minimal in recent months.
Clinical information flows for patients had improved when attending the local hospital emergency unit for urgent care. An alternative pathway had been developed for patients with long-term conditions, although work was ongoing to ensure that all these patients were receiving care in line with National Institute for Health and Care Excellence (NICE) guidance.
The 18-bed inpatient facility delivered positive outcomes for patients, despite the lack of permanent staff and living conditions that continued to be extremely poor. There were squalid cells with filthy drainage guttering outside each cell, leaking toilets and poor ventilation, resulting in the unit smelling strongly of urine. There was now a positive regime with most inpatients unlocked for a proportion of the morning and afternoon, although they still had to eat inside their squalid cells. Prison officers were not always available for the unit, leaving nursing staff to monitor at-risk inpatients with no cell keys.
5 prisoners were currently awaiting referrals to social care, of which 2 had waited over 2 months. There was no formal peer support or buddy scheme, which meant that support for prisoners with low-level social care needs was informal and not supervised or monitored.
Mental health provision had improved through investment in the service, recruitment and introducing a stepped care model for mental health support.
The integrated mental health service used group rooms, but vulnerable prisoners had limited access to group sessions. There were insufficient interview rooms for meaningful therapeutic interventions.
The recent introduction of a duty professional role had improved the initial assessment and allocation of prisoners to the appropriate level of support. There were 150 prisoners on the caseload during the inspection, 44 of whom were on the Care Programme Approach (CPA). Staff were allocated to attend ACCT case management reviews for prisoners at risk of suicide or self-harm, although late notice of the reviews affected attendance.
A range of self-help material was given to prisoners with low to moderate needs. There were health checks for prisoners prescribed mental health medicines.
Not all mental health team staff had completed their mandatory training in basic life support, safeguarding, infection prevention, fire safety etc. Caseload supervision ensured mental health care met individual prisoners’ needs.
The MH service had identified and assessed 18 prisoners for transfer to secure mental health hospitals in the last 6 months. The average wait for transfer was 80 days. While some of these prisoners were accommodated in the inpatient unit, others were held in the segregation unit due to behavioural problems; this was not an appropriate environment for prisoners with severe mental health problems.
Drug strategy meetings focused on reporting individual actions rather than taking a strategic approach to demand and supply reduction. However, the mental health and clinical substance use needs assessment had led to recent significant increases in the psychosocial provision. This was not yet matched by clinical substance use staffing, despite ongoing recruitment.
There were currently 199 prisoners on opiate substitution treatment (OST) and 333 on the psychosocial caseload.
A GP or non-medical prescriber saw new arrivals if they had a substance use problem. However, if prisoners arrived late on a Saturday and needed detoxification or stabilisation they might not be prescribed medicines until Monday, which was unacceptable.
There were no arrangements for overnight observations of any prisoner prescribed alcohol detoxification, which created significant risk. Monitoring of patients prescribed substitute and stabilisation medicines often did not take place due to insufficient clinical staff.
Inspectors observed supportive interactions with prisoners but administration of medicines was not confidential. Methadone and buprenorphine were prescribed appropriately. Prescribing reviews took place throughout the week, with one GP session and 6 non-medical prescriber sessions for substance use prescribing. There were no audits or reviews of prescribing.
Prisoners received most medicines via prescriptions. Health services staff could also administer and/or supply an appropriate range of medicines without a prescription through an authorised process. However, there were no records of staff trained and authorised to administer medicines without a prescription.
Custody Officer supervision of medicines queues had improved, although medication administration in the segregation unit was unsafe – this was rectified during the inspection.
Nurses, paramedics and pharmacy technicians administered medicines. Staff told inspectors that they followed up missed doses after the 3rd missed dose, and more quickly for critical medicines.
The medicines reconciliation rate was 20% within 72 hours and 40% in total, meaning that 60% of prisoners had not had their medicines reconciled during their detention. Staff also told us there were no specific processes to identify or prioritise prisoners with high-risk medical conditions or medicines.
At the time of the inspection, 63% of prescribed medicines were supplied in possession. Highly tradable medicines were administered only as supervised doses. Most prisoners had signed a compact agreement at reception and had an in-possession risk assessment. The monitoring of in-possession medicines was reactive and intelligence-driven, and they were not reviewed regularly.
Dental treatment and oral hygiene advice was available 5-days a week and was sufficient to meet prisoner needs. Waiting times during the inspection were around 2 weeks. Same or next day appointments were available for prisoners requiring urgent treatment, following clinical triage. 4 dental nurses and 2 dentists were in post, and there was good clinical oversight of the waiting list. The dental surgery was clean, well ordered and well maintained, and met infection prevention control requirements. Clinical governance of the dental service was robust, and staff received appropriate training and support. The surgery had access to interpreting services for non-English speaking patients.
As part of the survey, 29% of prisoners rated the overall quality of the health services as being either very good or quite good.
The CQC issued 3 Requirement Notice against Regulation Standards.
Recommendations: Health, Well-Being and Social Care:
- There should be a joint local operating procedure to optimise emergency response, including automated external defibrillation accessible for each house block and working area.
- Clinical supervision should be provided and recorded for all clinical staff, and mandatory training requirements should be fulfilled.
- Social care arrangements should meet the needs of all prisoners and the requirements of the Health and Social Care Act 2014.
- Transfers under the Mental Health Act should occur expeditiously and within the current Department of Health transfer time guidelines.
- Prisoners with substance use needs should receive substitution treatment in line with national guidance, and monitoring should ensure that their care is safe.
- New arrivals should receive their prescribed medicines promptly.
- The governance of medicines optimisation should ensure the competency of staff, and the monitoring and auditing of the effectiveness of the use of medicines.
Good Practice: Health, Well-Being and Social Care:
- The management of the high numbers of patients with blood-borne viruses was commendable, given the high turnover of prisoners. The system for ensuring effective patient information flow to and from the local emergency unit was improving continuity of care and patient outcomes.
CQC Requirement Notices Issued:
- Regulation 12: Safe Care and Treatment.
How the regulation was not being met:
The provider had not ensured that all risks to patients were assessed and appropriate action taken to reduce these risks.
The registered person did not have arrangements in place to fully assess and monitor the risks of patients requiring alcohol detoxification.
- Patients receiving alcohol detoxification treatment were not monitored by health care staff overnight for withdrawal symptoms or seizures.
- In April and May 2019, 62 patients were prescribed medicine for alcohol detoxification and withdrawal support. No overnight monitoring of these patients took place.
- The 62 patients who were prescribed alcohol detoxification medicine during April and May did not receive regular or consistent monitoring by suitably trained staff.
- Regulation 17: Good Governance
How the regulation was not being met:
The registered person did not establish and operate effective systems and processes to assess and monitor the quality and safety of the service. The provider’s systems and oversight of the service had not identified all risks to patients:
- The provider had not identified the risks associated with the absence of appropriate monitoring of patients with substance misuse needs who were prescribed medicines for stabilisation and withdrawal.
- At the time of the inspection, monitoring of the contents of the emergency bags did not ensure that the expiry date of glucagon was amended when removed from refrigerated storage.
- Records were not maintained of staff trained and authorised to administer medicines without prescriptions.
- Regulation 18 Staffing
How the regulation was not being met:
Staff had not been supported by regular supervision in line with the provider’s own policy.
- Out of 48 staff, 16 had not received any supervision in 2019.
- One member of staff who was employed for three months in 2019 had left having not received supervision.
- A new member of staff had not received their first supervision for four months.
- Mental health and psychosocial staff who worked at HMP Hewell had not had access to the electronic staff record system to complete their mandatory training.
- The overall mandatory training compliance on 14 June 2019 was 54.74%.