This report was on an unannounced inspection of HMP Winchester between 17 June to 05 July 2019, and was published in January 2020.
“Taking into account similar findings at other prisons, poor assessment scores and the deterioration in outcomes we saw at Winchester, notably on the local side of the prison, I gave serious consideration as to whether I should invoke the Urgent Notification process.” – Peter Clarke
General Points of Interest:
- HMP Winchester is in effect two prisons in one institution: a traditional category B local prison for adult and young adult men (housing 486 prisoners), and an adjacent but separate category C unit holding adult men (of which there were 122). Owing to the contrasting character and purpose of the distinct parts of the prison, each facility was considered separately against the healthy prison tests.
- Winchester was operating on a full complement of staff, and approx 70% of prison officers had less than 2 years’ experience in post.
- The number of incidents involving the use of force had increased significantly. There had been 260 incidents in the 6 months leading up to the inspection, compared with 162 in the same period before the previous inspection.
- There had been 7 self-inflicted deaths since the last inspection, of which 3 of them were in the previous 12 months.
- An average of 35 ACCT case management documents for prisoners at risk of suicide or self-harm were open at any one time, which was deemed as being high.
Healthy Prison Outcomes – Winchester Local:
|Rehabilitation & Release Planning||3||2|
Healthy Prison Outcomes – Winchester Cat C:
|Rehabilitation & Release Planning||3||2|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-Being and Social Care:
Staff were viewed as being under pressure, particularly in primary care. Innovations to meet the demand included the establishment of paramedic-led urgent response teams and providing incentives to attract new recruitments. There was too great a reliance on bank workers and agency staff, which was putting a strain on core staff as they had to undertake increasing amounts of developmental work, such as audits and kit checks.
Access to training was reasonable and staff received regular management and clinical supervision, although supervision was less consistent for primary care staff. Clinical records reflected the support offered and clinical decisions made.
A recent infection prevention audit indicated some environmental issues had not been progressed due to a backlog of outstanding work.
Most prison staff had undertaken emergency first-aid training. An emergency response team consisting of paramedic staff and nurses meant responses to all medical emergencies were prompt. Resuscitation equipment was being reviewed during the inspection, although existing kit was appropriate, regularly checked and appropriately maintained.
Information about health care services was provided at reception and during induction. A multi-agency health and well-being day held 4 months before the inspection had been well received, but there were no ongoing health promotion events. Health promotion material was not widely displayed, but patients were given a good range of information during consultations.
Smoking cessation services were provided in partnership with trained prison officers and were readily available.
New arrivals received a prompt initial health screening to identify any immediate health needs, and appropriate onward referrals were made. Staffing shortages meant fewer prisoners than usual had recently received a more comprehensive health assessment during their first 72 hours in prison, although the backlog was being addressed.
There was evidence of effective patient involvement. Wing health representatives attended regular health forums, which had triggered changes to practice.
The incident reporting system was effective and there was a systematic approach to sharing lessons learned.
GPs ran 11 weekly clinics from Monday to Saturday. The waiting time for a routine GP appointment was about 10 days, and the service was flexible enough to support prisoners with urgent needs. Out-of-hours’ support was available through NHS 111. Nursing cover was available 24 hours a day and 2 registered staff were on duty at night. Nurse-led triage clinics ran every day, and the team had nurse prescribers and an advanced practitioner.
The identification and management of patients with long-term health conditions required better coordination. A senior nurse managed all patients with conditions such as epilepsy and diabetes, supported by the GP. Daily nurse-led long-term conditions clinics were scheduled but did not always take place due to staffing pressures.
Health providers now routinely reviewed the reasons why patients did not attend appointments, and clinic non-attendance rates had declined since the previous inspection. External hospital appointments were managed effectively and patients requiring urgent treatment were prioritised.
The inpatient unit was staffed by prison officers and supported by visiting nurses. Positive interactions from officers were observed, who knew the prisoners in their care well. The unit catered for up to 15 patients and ran as 2 discrete areas supporting those with physical health needs and those with psychological or psychiatric needs. A weekly ward round, led by the psychiatrist, provided some clinical oversight, but it was unclear who was accountable for day-to-day care.
Prisoners with social care needs received good support. A prison-based social worker assessed prisoners within 72 hours when they were identified as having a potential need and produced a personal care plan. Access to mobility aids and adaptations were good. 2 health care support workers provided personal care to 9 prisoners on A wing and in the inpatient unit, and those receiving care packages were complimentary about the support they received.
For Mental Health needs, there was an open referral system, which included self-referral. A daily, single point of referral meeting reviewed all new cases to assess needs. All new ACCT cases were regarded as urgent and staff attended all first reviews and, where relevant, subsequent reviews. However, some reviews clashed, for example 16 were scheduled on 1 day alone. Routine referrals were seen within a week for an assessment, although access to routine treatment and support could take longer and there was a backlog of up to 14 weeks in some areas. In the survey, 65% of prisoners at the local site said they had a mental health problem.
MH services consisted of one-to-one interventions and group work and support included directed self-help and specialist psychological interventions. There was an active caseload of 109 patients, with 9 patients experiencing severe and enduring mental health problems who were managed under the CPA.
Most prison staff had attended mental health awareness training and ongoing training was planned. In the previous 12 months, only 9 out of 18 transfers to hospital under the Mental Health Act had taken place within the Department of Health’s timeframes.
Clinical substance misuse services and psychosocial interventions were provided by 2 separate providers. The well-resourced psychosocial team delivered case management and group work interventions to 158 prisoners – a third of the population. Peer mentors played a crucial role in providing harm reduction advice on psychoactive substances during induction and weekly wing drop-in sessions.
The clinical team was well managed and appropriately resourced. Substance use specialists assessed drug and alcohol dependent prisoners on arrival and prescribed first night treatment. Treatment regimes were flexible and patient-centred, and were reviewed regularly. During the inspection, 63 patients were prescribed opiate substitution therapy to stabilise or reduce their dependency.
The temporary closure of C wing accommodation, which contained 30 stabilisation cells presented a risk, but the prison and the clinical team worked together to mitigate those risks. Efforts were made to locate prisoners in hatched cells on other wings or in the health care department during their first 5–7 days. If this was not possible, cell doors could be open at night to allow for unrestricted observation.
Clinical and psychosocial teams arranged for prisoners to receive continued treatment on release, and bridging prescriptions were available for unexpected releases. A 3-week follow-up was carried out, and showed that 35% of prisoners had been involved with community services. Harm reduction advice was provided consistently and included a new pre-release information leaflet. Prisoners could now undertake training to administer the drug naloxone so they could treat an opiate overdose in the community.
The clinical pharmacist and team of technicians worked closely with other health professionals to provide a robust medicines management service. Increased staffing would have enabled pharmacy technicians to lead all medicine administration sessions and provide clinics. Most medicines were identified as being for single patient use and an appropriate stock could also be accessed.
The prison’s in-possession medicine policy ensured that tradeable medication was closely controlled and monitored. However, the absence of secure lockers in cells limited the effective use of in-possession medicines and increased the risk of diversion. Completed risk assessments were in place and were reviewed appropriately.
Supervised medicines were administered up to 4 times a day from wing treatment rooms and non-attendance was routinely followed up. Although inspectors observed officers supervising medicine rounds effectively, supervision was considered inconsistent and there was a risk that medication could have been diverted. Medicine administration in the segregation unit involved removing medication from secure storage for several patients at the same time, before carrying them to individual cells, which was not safe practice – an issue that was resolved during the inspection.
Not all the treatment rooms on wings were clean or wholly compliant with infection control standards, although some of the ventilation had been improved since the previous inspection. Routine checks of equipment were undertaken, including of refrigerator and room temperatures, however monitoring was inconsistent and needed greater managerial oversight.
Governance of medicines practice was effective and included well attended multi-professional meetings to review lessons learned from incidents, prescribing trends and clinical audits. Appropriate policies and procedures were in place and there was evidence that staff had read them and were fully aware of their contents.
As part of the survey, 35% 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:
- All clinical areas should be fully compliant with infection control guidelines.
- Access to sexual health services should be improved and barrier protection and related health advice should be available to prisoners to prevent sexually transmitted infections.
- Prisoners with long-term health conditions should be promptly identified and receive regular reviews, informed by an evidence-based care plan.
- Prisoners requiring treatment in hospital under the Mental Health Act should be transferred within the timescales established by the Department of Health.
- Officers should manage and supervise all medicine queues adequately, to protect patient confidentiality and prevent bullying and diversion.
Good Practice: Health, Well-Being and Social Care:
- None identified/reported.
CQC Requirement Notices Issued:
Regulation 12 – Safe care and treatment.
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:
The identification and management of patients with long-term health conditions did not ensure that all clinical risks were identified and managed safely:
- Not all patients arriving with long-term health conditions received a prompt initial review of this condition, or were prioritised when their clinical history indicated on-going need.
- Records reviewed showed evidence of some patients with poorly controlled diabetes and epilepsy not receiving structured care, which impacted on their health.
- Long-term health condition clinics were scheduled daily but often cancelled because of on-going staffing pressures within the primary care team.
- Very few patients with long-term health conditions had personalised care plans in place to inform their on-going care.
- Registers of patients with long-term health conditions were not well- established, up to date, and did not reflect the current patient population.