This report was on an unannounced inspection of HMP Cardiff between 15–26 July 2019, and was published in November 2019.
“Overall, this was an enormously encouraging inspection as it showed what can be achieved in a traditional local prison. HMP Cardiff disproves the clichés about inner-city Victorian prisons inevitably being places of squalor, violence and despair.” – Peter Clarke.
General Points of Interest:
65% of prisoners reported a mental health problem and 44% said they had a disability. 38% of prisoners arriving at Cardiff said they had a drug or alcohol problem.
The average mandatory drug testing (MDT) rate over the previous 6 months was 8.7% against a target of 18.5% (which also included tests for PSs).
Use of force was high and had doubled since the previous inspection. There had been 405 recorded cases compared with 201 previously.
With 435 recorded incidents during the 6 months prior to the inspection, the level of self-harm was over 3 times higher than at the previous inspection (123 incidents). There had been 10 deaths in custody, 2 of which were self-inflicted. Another prisoner died from health conditions for which PS use was a contributory factor.
There had been 451 ACCT case management documents opened in the previous 6 months, compared with 269 at the previous inspection. The standard of ACCT case management recording was variable, as were care maps. Triggers of self-harm were generally poorly defined. Case reviews were not always timely and not sufficiently multidisciplinary.
70% of the population had been at Cardiff for less than three months.
The prison released on average over 200 prisoners a month. Over the previous 6 months, 47% of prisoners had been released without having a home to go to.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||3||3|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
Leadership arrangements and systems for monitoring most aspects of clinical practice were effective. Attendance at some key clinical accountability meetings was inconsistent, which meant opportunities for senior staff to discuss the quality of care jointly were restricted. Local audit and quality assurance measures were also limited.
Patients were consulted about health issues through the general prisoner forum. There were no dedicated health representatives.
The service operated 24 hours a day and a nurse was on site at all times. There were few staffing vacancies, and nurses were used predominantly to manage and administer medicines. Staffing was insufficient in some areas, particularly in clinical substance use and mental health services. Access to training was good and there was evidence that staff had completed most mandatory sessions.
The health centre had sufficient waiting areas and clinical treatment rooms were spacious, well-equipped and mostly complied with infection prevention standards. Treatment rooms on wings were more variable.
Staff were trained to immediate life support level and officers spoke of responses to medical emergencies were prompt. Equipment was strategically located and the contents were appropriate and re-stocked after an incident.
The complaints process was not subject to quality assurance and just one senior clinician was responsible for its oversight. However, trends were monitored and health complaints were now managed confidentially. Responses mostly answered the concerns raised and some were resolved face to face, which was positive.
There was no prison-wide approach to health promotion and it was unclear what access prisoners had to some screening programmes for age-specific issues. There was no smoking cessation support, such as nicotine replacement therapy. Systems were in place to prevent communicable diseases and deal with any outbreaks.
Prisoners needed to approach nurses on wings to obtain an appointment with the healthcare team. As privacy was limited, patients could have been deterred from making an application. Access to all primary care clinics was good, and patients could see a doctor within two weeks for most routine appointments and there were slots for patients who were acutely ill. Clinic Non-attendance rates remained too high.
Patients with long-term conditions were identified on reception, but there were no regular clinics or systematic reviews of their care requirements. Trained nursing staff periodically ran some clinics, but care planning was minimal, which could have meant some patients’ needs were not met.
Many patients had treatment issues that encompassed substance use, mental health and physical problems, but there were no shared care arrangements, or any complex case management meetings to coordinate care, including complex prescribing, effectively. Access to external hospital appointments was good.
The need for mental health support was high – averaging 60 referrals per week. Prison’s referral data highlighted that 66.8% of new admissions were referred to the mental health service,
Prisoners requiring urgent MH support could be seen on the same day and within a minimum of 72 hours. However, in the previous 2–3 months, it was found that some patients had waited for 28 days to be assessed. A new assessment process and daily screening meetings had brought this down to a 6-day wait during July 2019.
Primary mental health support was limited: there was limited provision for patients with learning difficulties and staff had limited input into ACCT reviews.
Clinical substance misuse services and psychosocial support were delivered by different providers. These teams were co-located in the health care department, shared access to patient records and held weekly clinical meetings, which also involved mental health nurses.
The psychosocial service worked with 269 prisoners predominantly through 1-to-1 work, supplemented by in-cell packs. The standards of case work were found to be good.
51% of new arrivals reported drug and 33% alcohol problems. In the previous 6 months, 353 prisoners required alcohol detoxification and 199 were currently prescribed opiate substitution therapy. All were screened at reception and alcohol treatment started promptly, but it could take up to 2 days for prisoners to start methadone treatment. There were no designated clinics for starting or reviewing prescribing regimes.
Patients were not monitored adequately during stabilisation or detoxification. Alcohol detoxification should have been managed in the healthcare unit, but the lack of space meant only three out of 18 patients were located there. The 11 patients being stabilised on methadone were located on general wings without 24-hour monitoring, which was unsafe.
Strong community links and a shared database facilitated very good arrangements to ensure support in the community on release and 70% of prisoners continued with their treatment post-release. There was a high uptake of training to use naloxone.
Patients received medicines promptly from an in-house pharmacy. The pharmacy team clinically screened prescriptions and monitored prescribing which was good. However, they had little capacity to interact directly with patients and, as independent prescribers, their skills were underused. A medicines management group met regularly to discuss practice, audit activities and prescribing trends and develop policies.
Prisoners received supervised administration twice a day at 7am and 3pm, but night-time administration of medicines was limited. Officers’ supervision of queues was good. Staff followed up prisoners who had missed doses of high-risk medicines. About half of patients had their medicines in-possession.
The medication was usually supplied as labelled named-patient items that had a dispensing audit trail. However, nurses had to supply some patients with unlabelled daily in-possession medicines, including some tradable medicines due to the lack of routine night-time administration, which posed risks.
Pharmacy staff carried out weekly stock checks and quarterly date checks of all medicines in the prison. Medicines needing cold storage were kept in suitable fridges, which were regularly monitored, although out-of-range temperatures were not always managed appropriately. Medicines were not always stored safely or transported securely around the prison. Loose tablets and blisters were found in medicines trolleys on the wings, which was unsatisfactory.
Some other aspects of medicine management were poor, e.g. some medicines being found to be pre-prepared (‘potted-up’) to take to patients who could not attend clinic rooms. Controlled drugs were mostly well managed, but for some inadequately labelled doses of methadone that nurses had prepared for administration later that given day. All these practices increased the risk of errors and demonstrated that the prison’s oversight of medicines management was not sufficient.
As part of the survey, 35% 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:
- The negative survey responses from prisoners with a disability and prisoners with mental health problems should be examined closely to establish if services need to be changed. Any required changes should be implemented.
- Mental health services should assess prisoners’ needs promptly and provide timely support through an appropriate range of therapeutic interventions.
- Patients undergoing detoxification from alcohol, and/or who are stabilising on methadone should receive appropriate care that includes prompt access to timely assessment, clinical support and treatment, monitoring and ongoing assistance through regular reviews.
- Patients with long-term conditions, or complex care needs, should receive appropriate joined-up care and support that is subject to regular review.
- The range of psychosocial interventions should be expanded to include consistently delivered group work modules, mutual aid and peer support to meet the needs of the population.
- The pharmacy team should receive support to oversee medicines management and provide more patient-facing services, such as pharmacy-led clinics, medicine use reviews and counselling sessions.
- Medicines should be administered at times that ensure maximum clinical efficacy instead of being supplied as daily in-possession medicines to conform with the prison regime.
- Robust security measures should be put in place for transporting medicines around the prison and all medication should be stored securely until it is supplied to patients.
Good Practice: Health, Well-Being and Social Care:
- None identified/reported.