This report was on an unannounced inspection of HMP Kirklevington Grange between 12–23 August 2019, and was published in January 2020.
General Points of Interest:
There had been no violent incidents and no self-harm incidents in the previous 6 months.
Nearly a quarter of the population were being supported by the drug and alcohol recovery psychosocial team.
Two-thirds of prisoners accessed release on temporary licence (ROTL), and there had been only 6 failures out of the 18,068 ROTLs in the previous 6 months.
All prisoners were released into accommodation and with active bank accounts, and more than half left with a job or education place to go to.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||4||4|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-being and Social Care:
The complex arrangement of having 5 separate health service providers had led to some issues with effective communication between those providers. Strategic governance was reasonably good but there was a lack of focus on Kirklevington Grange in some meetings. A new lead provider model is due to commence from April 2020.
Prisoners were complimentary about health services, and service user feedback was positive. There had been attempts to establish a patient forum but uptake had been limited.
Few incidents had been reported, and trends were analysed but there was limited evidence of how lessons learnt were shared with staff, although a newsletter for health care staff had recently been produced covering this and other issues.
The confidential health care complaints system was accessible but few complaints were submitted. Responses were polite and answered the issues raised.
The health centre was bright and welcoming and operated like a small community surgery; prisoners appreciated the openness and community feel. They could make appointments in person or through the electronic information kiosks. The centre was open Monday to Friday, 8am to 5pm and until 6pm on 2 weekdays for prisoners returning from work to collect their medication. Methadone was administered between 7.45am and 8.30am every day, including weekends.
Staffing gaps had meant that there had only been one band 6 nurse managing the day-to-day service for a lengthy period instead of 2 nurses and a health care assistant Nurses from the nearby HMP Holme House were attending to cover the shortfalls. A full-time senior administrator based in the health centre organised internal and external health appointments and helped the unit to run smoothly. The head of health care for the prison was based at Holme House and the priority had been on this larger more complex prison. However, a recent review at Kirklevington had resulted in some additional staff training to extend services.
All providers managed mandatory training for health staff well and staff had access to professional development opportunities. All staff felt supported and received management and clinical supervision.
Emergency resuscitation equipment held in the health centre included an automated external defibrillator and oxygen. The emergency medication was checked regularly and in date, but the monitoring sheet did not itemise all the equipment and a few out-of-date items were found, which were replaced immediately.
An annual infection, prevention and control audit completed in November 2018 demonstrated mostly good compliance, but the action plan needed to be updated. Equipment calibration checks had been overdue since April 2019 but had been booked for September 2019.
Barrier protection and harm minimisation advice were available from health staff but not well advertised.
Although uptake of immunisations and vaccinations and NHS health checks were low, this had been identified by the provider. Staff had recently completed training to address this and clinics were being scheduled.
Smoking cessation support with access to nicotine replacement therapy was available but uptake was low.
Health staff completed a pre-admission assessment of prisoners to ensure that continuity of care could be provided. A registered nurse carried out an initial health screening of new arrivals within their first 24 hours. If the prisoner arrived after the health centre had closed, this took place the following day and any urgent needs were discussed with the 24-hour health team at HMP Holme House. A secondary health screening followed within 5 days.
GP provision was for 2 sessions and one advanced nurse practitioner session per week and patients were seen promptly. Some missed sessions had increased waiting times for routine appointments to 4 weeks, which was too long, but this had been addressed. There was access to community GP services out of hours.
Prisoners had good access to a nurse every weekday for advice and triage. Some patients with long-term conditions were seen by the GP. A nurse had received additional training to monitor respiratory conditions but there were no other nurse-led clinics to manage long-term conditions. Reviews were not systematic and care plans were limited.
External hospital appointments were well managed with prompt referrals. Prisoners attended hospital appointments on their own or with an escort, subject to risk assessment.
Prisoners were offered a pre-release appointment a week before their release, and patients received a GP discharge letter detailing the care they received and any continuing medications.
The integrated mental health team based at Holme House provided a responsive service through a stepped model of care to patients at Kirklevington Grange.
There was regular weekly input by 3 members of the MH team providing emotional health and well-being support, self-help guidance, counselling and psychological treatments, including eye movement desensitisation and reprocessing therapy, and interventions based on cognitive behavioural therapy.
The number of referrals fluctuated but around 9 each month, and were received through self-referral and from health and prison staff. An initial mental health assessment was carried out within 4 working days. More urgent assessments could be facilitated, including out of hours through the duty worker at Holme House. The current team caseload was 14 and patients were seen promptly for treatment. Physical health checks were carried out for individuals on antipsychotic and antidepressant medication.
Mental health staff attended the first ACCT case management assessment for prisoners in crisis, if available, and subsequent meetings if the prisoner was on their caseload. Primary care health staff attended all these meetings.
The drug and alcohol recovery psychosocial team comprised a team manager who worked between Kirklevington Grange and Holme House, 2 full-time recovery workers and a part-time family worker, and it had access to a connecting communities lead. The team was actively supporting 60 prisoners at the time of the inspection (23% of the population) and assessment was prompt. Structured one-to-one sessions were supplemented by excellent individual workbooks, and acupuncture and relaxation were popular.
The clinical substance misuse team based at Holme House visited when needed. There was access to 2 non-medical prescribers, including the clinical lead, who confirmed prisoners’ previous prescribing regimes promptly to enable effective and safe treatment continuity. Prescribing was flexible and care was regularly reviewed jointly. Prisoners were fully involved in their care and were positive about the support they received. During the inspection, 13 prisoners were receiving methadone, of whom 11 were reducing and 2 were on maintenance doses.
Naloxone training was delivered to every new arrival during induction and offered again to all prisoners on their release, which was thorough. Over 90% of officers had also received naloxone and overdose awareness training, which was impressive.
Medicines were supplied and dispensed promptly by the pharmacy at Holme House. Most medicines were supplied on a named-patient basis with information leaflets.
Patients collected in-possession medication from the health centre and signed a printed script to verify receipt along with the nurse in attendance. All new arrivals on medication had a medication review within 48 hours. Patients were responsible for re-ordering their own prescriptions to prepare them for release, which was positive.
A pharmacist from Holme House had completed and signed for regular controlled drug checks. The emergency stock cupboard was well maintained and nurses identified when stock was used.
In line with national guidance for category D prisons, gabapentin and pregabalin (reclassified as controlled drugs in April 2019) were given weekly in-possession to allow prisoners to go to work and participate fully in the regime. Regular recorded spot checks to ensured compliance.
There were no pharmacy clinics or medicine use reviews, although the regional pharmacist had just qualified as a non-medical prescriber and intended to set up a monthly medication review clinic for prisoners.
As part of the survey, 69% 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:
- Responses to medical emergencies should be routinely recorded and monitored, and there should be comprehensive checks to ensure that all emergency resuscitation equipment is in good order.
- The prison should further develop nurse-led clinics for prisoners with lifelong conditions, underpinned by evidence-based care plans, and trained and supervised staff should undertake assessment, treatment and reviews.
- There should be regular pharmacist input into the prison to ensure effective management of stock, and prisoners should have access to medicine use reviews and pharmacy advice.
Good Practice: Health, Well-being and Social Care:
- Peer mentors went into local schools, colleges and youth offending teams to talk about their experience of substance use and recovery, which helped to raise awareness.
CQC Requirement Notices Issued: