This report was on an unannounced inspection of HMP Littlehey between 22 July to 02 August 2019, and was published in December 2019.
General Points of Interest:
Levels of self-harm had increased since the previous inspection but remained low, with many incidents attributable to a small number of prisoners. The quality of assessment, care in custody and teamwork (ACCT) case management documentation for prisoners at risk of suicide or self-harm was mostly good, and improving. Mental health staff input to ACCT reviews was effective.
There had been 1 self-inflicted death since the previous inspection. Recommendations from the Prisons and Probation Ombudsman’s (PPO’s) report had been acted on swiftly, with actions being put in place to mitigate identified shortfalls.
As a likely consequence of the large proportion of older prisoners, there had been 30 deaths from natural causes since the previous inspection. 48% of prisoners were over the age of 50.
Concerns remained as whether there was sufficient oversight of previous recommendations to ensure continued adherence to the required actions. This was particularly evident in the PPO reports for deaths from natural causes, where there had been several repeated recommendations.
All uniformed staff had been trained in some form of mental health awareness in the previous two years, with 38% having more specific training, which helped them to identify prisoners who needed support.
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:
Only 7 clinical incidents had been reported each month since April 2019, mainly regarding minor medicines administration errors. Lessons were learned from these incidents, and the service risk register reflected ongoing significant concerns.
Health trainers brought views from health service users and wing community meetings to a well-established patient engagement group (PEG). Ideas arising from this group and the rolling patient satisfaction survey influenced service changes.
There had been about 18 complaints per month since April 2019, via an improved and confidential healthcare complaints system. Most patients were seen by one of the clinical leads as part of this process, ensuring that complainants were heard. The most frequent concerns were about the dental service and medicines issues. Response letters were timely and focused on the issues raised.
Bland healthcare rooms in reception and induction clinical rooms were unwelcoming but functional. The use of the rooms was being reorganised to make the reception process more efficient.
Primary care staff were available from 7.30am to 7.30pm on weekdays, with slightly shorter hours on Fridays and at the weekend. The large multidisciplinary team had a good mix of skills. Mandatory training compliance rates met provider standards, and staff had further access to specific training that was relevant to their role. The service was well led and supported by skilled clinical leads. All staff had regular clinical and line manager supervision, and they that they felt supported. Health services staff were clearly identifiable, and their interactions with patients were caring and professional.
The patient records that were sampled on SystmOne were informative, and demonstrated patients’ involvement in their care. A clinical audit of records and other clinical activities took place, in accordance with the providers policy. Audit reports contained learning points which were acted on.
Health promotion by health services staff was prominent, with campaigning on key issues for men. 18 well-trained and supervised prisoner health trainers undertook some physical health checks in reception and on the wings, such as for weight and blood pressure, and were effective at encouraging their peers to access health services.
Good smoking cessation support was available, including for those who wanted to stop vaping.
Since January 2019, the average intake for new receptions were around 12 per week.
Primary care services scheduled around 6,000 non-urgent appointments per month. Patient attendance had improved and was generally good, with only about 6% of prisoners not attending their GP appointments and 15% not attending their dentist appointment since April 2019.
There was prompt access to a full range of primary care clinics, including optometry, physiotherapy and sexual health. Drop-in triage clinics took place daily at 11.30am. There were GP clinics each day, with short waiting lists, vacant slots for emergencies and non-urgent waits of 2–7 days, on average – a noteworthy improvement since the previous inspection. On-call GPs were rarely used.
Joint pathways for pain management were particularly effective. This ensured that only prisoners with clinical need received medicines and that prescribing levels were kept low, with monthly reviews by the doctor, pharmacist and physiotherapist offering alternative approaches to management.
Referrals to secondary care services were well managed, although demand had outstripped the 8 escorted slots made available by the prison each day. This was managed daily but required a review of capacity. Video consultations with hospital specialists via Skype were being introduced, to complement existing specialist clinics and reduce some of the pressure on prison health services.
At the time of the inspection, 10 prisoners were receiving social care from 6 full-time social care assistants.
The Mental Health team were available 5 days a week and prison staff could call a mental health nurse out-of-hours for advice.
The MH service was highly responsive to ongoing and emerging needs, with approx 50 new referrals each month since April 2019. Routine referrals were seen within 7 days, and a new Friday drop-in service had increased the number of referrals for assessment.
The MH team provided diagnosis and treatment for dementia. Patients could access a hospital consultant remotely using video conferencing facilities, which was innovative.
Staff attended ACCT case management reviews for patients on their caseload and also new prisoners on an ACCT. The team provided individualised crisis plans for segregated prisoners needing mental health support. This ensured a consistent approach between mental health staff and prison staff, so that these prisoners were supported.
Physical health checks, including regular blood tests, were completed for patients on mental health medication. Clinical records were good, with needs assessments and risk assessments completed, and care plan objectives showed patient involvement.
At the time of June 2019, only 13 patients had been in opiate substitution therapy, with approx 50% on reducing doses, which was appropriate. Around 130 patients were engaged in psychosocial therapy, with relaxation therapy and acupuncture proving popular. An extensive range of one-to-one and group sessions and programmes were available, and these could be assembled into bespoke individual packages of treatment. Joint dual diagnosis work was available for those with co-existing mental health and substance use problems.
Each wing had a prisoner recovery champion who was suitably trained and supervised. Alcoholics Anonymous held weekly meetings to provide peer support, and plans to reintroduce Narcotics Anonymous were advanced. The Integrated Substance Misuse Team (ISMT) made links with community drugs teams to begin throughcare for patients being released. Suitable arrangements were made to continue OST and provide naloxone to take home, to help to minimise harm.
Pharmacy services were provided by a pharmacist who was an independent prescriber. Medicines were supplied, transported and stored in safe and appropriate ways. There was a pharmacy room on each site, although the room on the Woodlands site over-heated (above 25 degrees centigrade) during hot weather, which was contrary to national guidance.
Patients could contact the pharmacist via an application form, the nurse triage clinics or at the medicines administration hatches. The pharmacist was easily accessible via weekly clinics and monthly pain clinics, and undertook medicines use reviews.
A total of 1,140 prisoners (94% of the population) had medicines in-possession, with in-possession risk assessments being completed and reviewed by the pharmacist at each repeat prescription. All shared cells were equipped with secure storage lockers for medicines.
Few patients (an average of 40 at a time) had supervised medicines administration, which occured daily, at 7.45am and 4.30pm, at each health centre. At these times, waiting rooms were congested but there was good supervision by officers.
The pharmacist chaired regular, minuted medicines management meetings, and these were well attended by stakeholders. New additions to the formulary, new operating procedures, concerns and incidents, including those at other prisons, were discussed there. There were extensive clinical audits to monitor prescribing trends and medicines use, and to ensure safety.
As part of the survey, 74% 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:
- Patients requiring care under the Mental Health Act should be transferred promptly and in accordance with NHS guidelines.
Good Practice: Health, Well-Being and Social Care:
- The multidisciplinary approach to pain management ensured that patients had optimal opportunity to manage their pain and ensured that only those with clinical need received medicines.
- The whole-team approach to those in palliative care, led by the specialist consultant and advanced practitioner, was well integrated with strategies for the care of older prisoners and social care, so that patients in terminal care could die in dignity at the establishment.
- Mental health crisis plans for prisoners in segregation ensured a consistent approach between mental health staff and prison staff, and helped to mitigate some of the effects of segregation.
- There were extensive clinical audits to monitor prescribing trends and medicines use, and to ensure safety.
CQC Requirement Notices Issued: