This report was on an announced inspection of HMYOI Feltham A between 04–19 July 2019, and was published in October 2019.
“Levels of self-harm had tripled since the previous inspection and were now 14 times higher than they were in January 2017.” – Peter Clarke
General Points of Interest:
HMYOI Feltham A is an institution in West London that holds children aged 15 to 18. It is jointly managed with an adjacent establishment, Feltham B, that holds young adults. On this occasion, both establishments were inspected concurrently.
Self-harm was more than 3 times that at the previous inspection – 242 incidents in 6 months, despite the decrease in population between the 2 inspections. Many of the self-harm incidents were a response to the poor and unpredictable regime children experienced.
There were concerns that ambulances were not always called immediately when a member of staff used an emergency code to summon assistance.
The number of intelligence reports submitted to the security department had increased significantly since the last inspection, increasing from 960 to 3,432 during the previous 6 months.
There were serious failings in the oversight of use of force. The safety team had a backlog of more than 900 use of force reports which staff had not completed.
Healthy Prison Outcomes:
|Jan 2019||Jul 2019|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
Patient engagement was in the initial stages of development. Plans were in place to enable children to express their views about health care through a new community forum and patient feedback questionnaires were handed out after each health care intervention.
Staffing levels and the skills mix were adequate to meet children’s needs. Several new staff were due to take up post following a recent recruitment drive.
Training and professional development opportunities were good and clinical records that we reviewed conveyed care needs appropriately. Staff supervision was good but not monitored.
There were sufficient clinical rooms in health care, which were fit for purpose. An infection prevention and control audit had been completed and a subsequent action plan put in place to improve standards in some areas. There was now a cleaning schedule and outstanding maintenance issues were highlighted to senior prison staff.
An independent health complaints process had recently been introduced. Some children still used prison forms, but confidential healthcare forms were available. Most responses to the few complaints raised were dealt with face to face. Written responses were brief and focused.
The local delivery board had started to discuss the establishment of a whole-prison approach to the health and wellbeing of children, which inspectors welcomed. Relevant bespoke health promotional activities took place throughout the year.
Children could access health services using a clear pictorial application form. Health staff collected the applications each day, delivered appointment slips and followed up non-attendance with children.
Clinics and services were appropriate to need. DNA rates were too high because of access constraints, for example in June 2019 they stood at 58% for the GP and 80% for the optician which was a grossly inefficient use of NHS resources. There were several reasons for non-attendance, but the most frequent was the inability of prison managers to move children to appointment.
A Mental Health practitioner acted as daily duty worker and attended most ACCT reviews, supported safer custody events and meetings, and ensured good integration with the prison.
Mental Health referrals were reviewed each day and 56 children were on the treatment caseload at the time of the inspection. Formulations and clinical records on SystmOne were very good. There was an open referral system and children could self-refer.
The enhanced support unit (ESU) was intended to provide a positive therapeutic environment for children with additional mental health support needs through a range of activities and interventions. However, the regime was often curtailed, which was not therapeutic, and the lack of prison-enabled purposeful activity in the unit placed additional pressure on the clinical team and reduced their capacity for outreach to children not placed on the unit.
About 80% of prison officers had been trained in aspects of mental health since 2018 which was an improved situation.
The Substance Misuse team was now fully staffed, an improvement since the last inspection. The team included a family worker and a behavioural change worker who assisted former gang members with recovery. The team also continued to contribute to ACCT reviews, safer custody and drug strategy meetings.
The efficiency of the Substance Misuse team was hampered by lack of access to patients and the failure to attend rate had been as high as 67% in some of the previous 6 months.
The pharmacist chaired regular medicines management meetings which were well attended by stakeholders. New additions to formulary, new procedures, concerns and incidents were discussed, including those at other prisons. There were regular clinical audits to monitor prescribing trends and medicines use.
Few patients were taking medication and only occasionally had medicines in possession. In-possession risk assessments were completed conscientiously.
Since April 2019, an average of 56% of patients had failed to receive their administered medicines. Inspectors were told of examples whereby a patient had had a legal visit and was unable to attend for his medicines, and it was unclear when the patient had received that dose of medication. Another patient was prescribed medicine to treat epilepsy, with one tablet to be taken twice a day. The administration times were 7.45am and 4.30pm which were not 12 hours apart and were clinically inappropriate. The four administration times for an antibiotic for one patient started at 7.45am and finished at 8pm leaving 12 hours with no dose, which did not optimise the therapeutic benefit of the antibiotic.
Medicines, including controlled drugs and other not-in-possession medication, were administered from a newly designated room in reception at Feltham A. There was no fridge to store medicines that needed to be kept cold. Staff said that the room could become very warm, but the air temperature was not being monitored to ensure it was cool enough.
At the time of the inspection, a security grill had not been fitted at the entrance to the reception room and the door had to remain open. The only means of securing the entrance from unauthorised access by a patient was to push the medicines cabinet/trolley across the open door. Not surprisingly, there had been incidents of patients attempting to enter the room or thrust their arms inside.
Primary care nurses identified children due for release (18 a month since April 2019) and saw each individually to prepare through care. This included take-home medication as necessary and a letter for the GP. Mental health and substance misuse teams engaged with community agencies to ensure continuity of support and followed children up after release to encourage them to make use of community services, which was good.
The CQC issued 1 Requirement Notice against Regulation Standards.
Recommendations: Health, Well-Being and Social Care:
- The inpatient unit should only be used for health and therapeutic purposes. Children should not be located on the inpatient unit to address operational issues. (Repeated recommendation)
- The prison partnership board should ensure that patients access health and substance misuse services at the required times and receive their medicines in a safe manner at the prescribed times. These arrangements should be monitored to ensure that the health of patients is not compromised.
Good Practice: Health, Well-Being and Social Care:
- None identified/reported.
CQC Requirement Notices Issued:
Regulation 12 – Diagnostic and screening procedures Treatment of disease, disorder or injury.
How the regulation was not being met…
- The registered persons had not done all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. In particular, some risks associated with medicines administration.
- The provider’s risk assessment of the medicines administration area on Feltham A did not fully assess the environmental concerns impacting on medicines administration, and the risk assessment had not been reviewed promptly.
- A patient was given prescribed medication without any water to swallow the tablet.
- Medicines were given at inappropriate intervals:
- One patient received epilepsy treatment at variable intervals and not as prescribed.
- The provider had not considered the use of in-possession medication to enable children to take their medicines when most effective.