This report was on an unannounced inspection of HMP Bullingdon between 01–12 July 2019, and was published in October 2019.
“Even though there were indications that illicit drugs were becoming harder to obtain, the fact remained that more than half of the prisoners believed it was easy to get hold of them, and around one in five said that they had acquired a drug habit since coming into Bullingdon.” – Peter Clarke
General Points of Interest:
Staffing levels had increased substantially since the previous inspection, leading to 67% of prison officers having less than 2 years experience.
75% of the population had been in the prison for 6 months or less.
Self-harm levels were similar to that at the time of the previous inspection, and still much lower than at other local prisons. There were 25 prisoners subject to assessment, care in custody and teamwork (ACCT) case management procedures during the inspection.
Since the previous inspection, there had been 5 self-inflicted deaths.
Constant supervision was used often but there was only one suitable cell in which this high level of support could be delivered effectively. Too often, prisoners were locked in a normal residential cell, with an officer seated outside checking them through the observation panel, which was unsafe.
Prisoners had submitted 3,621 complaints in the previous six months, which was more than at other local prisons and in the same period at the time of the previous inspection.
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:
Learning from incidents, audits, complaints and patient surveys informed service delivery, and lessons learnt were now shared with staff. Considerable progress had been made on Prisons and Probation Ombudsman recommendations from death in custody reports relating to health care practice, leading to improved initial health screening and more regular mental health staff attendance at ACCT case reviews.
Healthcare appointment slips were sometimes given out to prisoners after the appointment time had passed. This problem had been repeatedly raised by prisoners through the monthly consultation meetings, and staff were seeking to address it.
The chronic staffing shortages found at the time of the previous inspection had been mitigated by recruitment to key positions and use of regular agency staff, who now felt part of the team. Raising the skills and competency levels of staff and ensuring a cohesive team had been a priority.
Health services staff had received life support training, and responded to medical emergencies 24 hours a day. They had good access to suitable and well-checked emergency equipment. The introduction of a paramedic had been a useful addition to the team.
Staff handover meetings and a weekly multi-disciplinary complex case meeting demonstrated effective joint working to promote good standards of care. Health services staff were aware of their safeguarding responsibilities and had received relevant training.
The management of health care complaints had improved. Patients could complain about their treatment in confidence, and forms were available on the residential units. The responses sampled had been timely and included details of how managers had investigated them.
There was no prison-wide health promotion strategy, but the service was involved in joint initiatives with the prison. Health promotion material was now displayed in the waiting area and across the prison, following the national calendar of health topics.
Immunisation and blood-borne virus screening were discussed at the second reception health screen. There was good smoking cessation support and access to community screening programmes, including retinal and abdominal aortic aneurysm screening.
The inpatient unit had improved and admission was based on clinical need. It was used for patients with physical, mental health and social care needs. Managers had reviewed the admission and discharge criteria, ensuring appropriate use of clinical beds. There was a regular team of nursing staff and discipline staff on the unit, who knew the patients well and delivered a good standard of care.
On release, there was also a choice for patients to receive their information via a mobile phone app. This enabled community GP services to continue their care in a timely way.
There was a comprehensive memorandum of understanding between the prison and the local authority to ensure the delivery of social care to those who met the threshold. Local authority arrangements for the assessment and provision of social care were good. Prisoners were able to self-refer.
A stepped model of care was provided by two mental health teams, who worked well together to provide high-quality support for individuals with mild-to-moderate to more complex needs. However, more resources were needed, particularly to enhance the range of primary mental health services available.
The primary mental health team (PMHT), comprised 3 mental health nurses, an assistant practitioner and a team leader. The team was available 7-days a week and responded to urgent need promptly, and routine referrals within 5 days. Prisoners could self-refer, and other referrals came from health services and prison staff. The PMHT undertook approximately 65 assessments per month and were the gatekeepers to the secondary mental health service. Servces offered included self-help material, psychoeducation sessions and computerised cognitive behavioural therapy sessions on an individual basis. However, they did not run any groups. The assistant practitioner completed well-being assessments, which promoted self-awareness and goal setting.
A process had been introduced to increase attendance at ACCT case reviews. The mental health teams met at least twice a week to discuss referrals.
At the time of the inspection, there were 41 patients on the in-reach team’s caseload, with 29 being managed effectively under the Care Programme Approach (CPA). Access to psychiatry was good, with six sessions per week.
Physical health checks, including regular blood tests, were completed for patients on mental health medication. The clinical records sampled were good, with thorough risk assessments, comprehensive progress notes and care plans demonstrating patient involvement.
The Substance Misuse team saw all new prisoners during induction, offering support and harm minimisation advice. Prescribing to meet clinical needs was available on the first night. About 240 patients were engaged in psychosocial therapy, representing an increase since the time of the previous inspection. A reasonably wide range of one-to-one and group sessions was available although some therapeutic options were not running.
Joint dual diagnosis work, for those with co-existing mental health and substance use problems, was available.
Substance Misuse clinical management was consistent and included joint 5-day, 28-day and 13-week reviews with psychosocial practitioners, an improvement since the previous inspection.
During the inspection, 198 patients were receiving opiate substitution therapy (OST), including methadone and buprenorphine. Few were on reducing doses, which was appropriate.
Community drug services no longer accepted referrals from the provider, which introduces a potential risk of relapse on release. Those in receipt of OST were linked with community services and were released with a prescription to last them until they attended their first community appointments. Take-home naloxone had been introduced as part of the discharge process, which helped to minimise harm.
Medicines were supplied by the in-house pharmacy. There was now a dedicated medicines management team, mainly consisting of pharmacy technicians, who were based on the residential units. The management of stock and the ordering of prescriptions had improved as a result, and provided consistency to patients. Supervised medicines were administered safely and efficiently from the residential units twice a day, with additional provision for night-time administration by nurses, although this was rarely used.
A weekly review of patients’ non-attendance for medication ensured that staff were adhering to the policy and ascertaining the reasons for non-attendance.
There was an in-possession policy, and risk assessments were carried out, although the reasons for decisions were not always recorded. These assessments were regularly reviewed. Around 50% of medicines were given to patients in-possession.
All prescriptions were clinically screened by the pharmacists, and some joint medication reviews had been carried out between pharmacist and the independent pharmacy prescriber. There were monthly risk meetings, which included a good focus on the management of medicines.
As part of the survey, 38% 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:
- Health promotion material should be available throughout the prison, in a variety of languages and formats, to meet the needs of the prison population.
- A comprehensive primary mental health service should be provided, offering a full range of support for prisoners with mild and moderate mental health problems.
- The substance use psychosocial therapy needs of prisoners should be met in a timely manner.
- Patients risk-assessed as not being able to have their medicines in-possession should not be given their medicines in this way.
Good Practice: Health, Well-Being and Social Care:
- The dietician provided an innovative approach to reviewing the nutritional value of prison food and helping individuals to make informed choices to improve their health.
CQC Requirement Notices Issued: