This report was on an announced inspection of HMYOI Feltham B between 04–19 July 2019, and was published in October 2019.
“…the results of this inspection mark a significant achievement for an establishment that has faced similar pressures to many others that have not been able to maintain, let alone improve, their overall level of performance in recent times.” – Peter Clarke
General Points of Interest:
HMYOI Feltham B holds convicted male prisoners aged between 18 and 20. It is situated adjacent to and comes under the same management as Feltham A, which hold boys aged between 15 and 17. On this occasion, both establishments were inspected concurrently.
The number of adjudications carried out was comparable with that at the time of the previous inspection, with only 19 adjournments, dating back no further than 2 months, compared with over 400 at the time of the previous inspection, some of which dated back over 12 months. The prison had made great progress in the monitoring and managing of adjourned adjudications.
The number of self-harm incidents had increased considerably over the previous 6 months, but remained lower than at similar prisons. The number of assessment, care in custody and teamwork (ACCT) case management documents for prisoners at risk of suicide or self-harm opened in the same period had also increased, with 82 open at the time of the inspection.
The quality of ACCT case management documents for prisoners at risk of suicide or self-harm was good, with consistent case management and multidisciplinary reviews. There had been an improvement in the quality of the care maps since the previous inspection.
The strategic management of self-harm was inadequate. The safer custody strategy was a generic document ‘borrowed’ from HMP Downview, and reference to that prison and the management of women could still be found in it.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||2||3|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
A stable healthcare management team had embedded improved governance systems since the previous inspection. Clinical governance meetings had been introduced, which provided a forum for lessons learned from audits and incidents, and for complaints to be reviewed.
Patient engagement was in the initial stages of development. There were plans to enable prisoners 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 prisoners’ needs. Several new staff were due to take up posts following a recent recruitment drive. Training, supervision and professional development opportunities were good and the clinical records that we reviewed appropriately conveyed care needs.
There were sufficient clinical rooms in the health centre, and these were suitable for use. An infection prevention and control audit had been completed, with a resulting action plan to improve standards in some areas. A cleaning schedule was now in place, and outstanding maintenance issues were highlighted with senior prison staff.
Arrangements for responding to medical emergencies were appropriate but control room staff contacted officers on the residential units about the situation before calling an ambulance, which potentially placed prisoners at risk.
There was no independent health care complaints process, and all patient concerns were raised through a generic prison form, which was inappropriate. Inspectors observed a health care complaint that had not been picked up by the health care team. Despite this, responses to the few complaints raised were mainly dealt with face to face, and written responses were respectful and focused.
The local delivery board had begun to discuss the creation of a whole-prison approach to the health and well-being of prisoners. Effective bespoke health promotional activities took place throughout the year.
The patient information pack provided on arrival at the prison was good, and some of it was now available in languages other than English. Smoking cessation support was available for new arrivals and there were appropriate policies on communicable diseases.
Prisoners could access health services using a clear pictorial application form. Health care staff collected the applications each day, delivered appointment slips and followed up patients who did not attend.
The GP was available for urgent appointments, and to see non-urgent cases within 48 hours. GP advice was also available out of hours, and nurses were available 24 hours a day. Visits were made to prisoners on the residential units if they were unable to attend the health centre.
The range of available clinics was appropriate to need. DNA rates for appointments were far too high; in June 2019, for example, these had been 58% for the GP and 80% for the optician, which was a grossly inefficient waste of NHS resources. Although there were several reasons for non-attendance, the most frequent was the inability of prison managers to move patients to appointments.
The prison provided 2 hospital slots a day for emergencies and routine hospital appointments, which was sufficient to meet need.
Primary care nurses identified patients due for release (60 per month since April 2019) and saw each individually, to prepare throughcare, which included take-home medication as necessary and a letter for the GP.
Prison officers and health care staff on the inpatient unit delivered individualised care, and innovative reflective practice groups were attended by nurses and officers, which helped them to learn jointly from practice. There continued to be admissions for non-clinical reasons (10 since April 2019), which introduced unnecessary risks to the care of sick and vulnerable prisoners.
A Mental Health practitioner acted as daily duty worker. The duty worker attended most ACCT case management reviews and safety-related meetings, ensuring good integration with the prison. They also ensured that assessments for new arrivals occurred promptly.
An average of 47 new prisoners were screened for mental health problems each month. There was an open referral system and prisoners could self-refer. Referrals were reviewed daily, and 96 were on the treatment caseload at the time of the inspection. Formulations and clinical records on SystmOne were good. The range of treatments included psychological interventions, one-to-one work and guided self-help. Attendance for therapy was higher than for other clinics, at 91%, which was good.
Substance Misuse team staffing had improved since the previous inspection, and staff now had access to appropriate training and supervision. Efficient working had been hampered by an unplanned office accommodation move, which had dislocated workers from access to patients’ clinical records on SystmOne.
The efficiency of the Substance Misuse team was hampered by a lack of access to patients, with the failure to attend rate as high as 50% during the previous 6 months.
The pharmacist chaired regular medicines management meetings, which were well attended by stakeholders. There, new additions to the formulary (a list of medications used to inform prescribing), new procedures, concerns and incidents, including those at other prisons, were discussed. There were regular clinical audits to monitor prescribing trends and medicines use.
Few patients were taking medications, and even fewer had medicines in-possession. In-possession risk assessments were completed well. Although secure in-cell lockers for storing medicines had arrived at the prison, they had not yet been fitted at the time of the inspection.
Supervised medicines administration took place daily at 7.45am, 11.30am, 4.30pm and 8pm in 2 groups of 3 units. During these visits, officers brought patients to the nurses in the unit activity rooms. During the inspection, in one group, 2 patients had already gone to their gardening activity when nurses arrived to administer medication, and the nurses had to follow them. Although the nurses located the patients, there was difficulty in providing water to help them to swallow the medication. Inspectors observed one patient having to swallow a capsule with no water, which risked the capsule dissolving in his throat or oesophagus, potentially damage the surrounding tissue, as well as the medication not achieving the desired therapeutic dose.
As a result of having to follow patients to different locations to administer medication, doses were not always given at the prescribed times; this practice was highly inefficient, created abnormal expectations among the prisoners and did not prepare them to be responsible consumers of health services following release. Since April 2019, an average of 56% of patients per month had failed to receive their not-in-possession medicines, which was unacceptably high.
As part of the survey, 48% of prisoners rated the overall quality of the health services as being either very good or quite good.
The CQC issued 1 Requirement Notice against Regulation Standards.
Recommendations: Health, Well-Being and Social Care:
- Prisoners should have access to health and substance use services at the required times, and receive their medicines in a safe manner at the prescribed times.
- Patients should be able to complain about health services through a well- advertised, quality-assured, independent health care complaints system.
- The inpatient unit should be used only for clinical purposes, and prisoners should not be located there to address operational issues.
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.