“The improvement from poor to good for respect represented a remarkable achievement since the last inspection. The squalor and filth we saw in 2017 had gone, replaced by clean and decent living conditions for the vast majority of prisoners.” – Peter Clarke
This report was on an announced inspection of HMP Liverpool between 27 August to 06 September 2019, and was published in January 2020.
General Points of Interest:
The population had been reduced by approximately 500 prisoners and 22% of cells had been taken out of use to improve decency.
Levels of self-harm had increased since the last inspection and were high compared to similar prisons. There was evidence that the increase was due to the actions of some prolific self-harmers and more robust recording of incidents. During the previous 6 months, there had been 397 incidents of self-harm by 48 prisoners compared to 184 incidents by 108 prisoners at the last inspection. During the previous 3 months, self-harm incidents had started to fall.
During the previous 6 months, 528 ACCT documents had been opened which, in the context of the reduction in population, was more than the last inspection and at similar prisons. The prison had worked hard to improve the quality of ACCT documents and reviews were now multidisciplinary and completed on time.
There had been 6 self-inflicted deaths since the last inspection in 2017.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||2||4|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-being and Social Care:
The lead provider and main subcontracted providers had their health services to that of Better Health Liverpool.
A Better Health Liverpool user voice forum ensured that prisoners were consulted to inform service developments. Incident reporting systems were appropriately used and there was clear evidence of lessons being shared with staff to improve patient outcomes.
Health care staff were a prominent and accessible presence on the wings and staffing had stabilised since the last inspection, although there remained too many vacancies in the primary care nursing team and regular bank and agency staff were routinely used. Agency staff had equal access with substantive staff to the good range of training, managerial support and regular supervision.
The health care centre was a good facility which complied with infection prevention standards. There were sufficient treatment rooms to meet demand. The standard of cleanliness and facilities in wing treatment rooms was found to be varied.
The health care complaints process was well advertised and matron drop-in clinics now enabled face-to-face resolution of many concerns. Most written responses focused on the issues raised by patients and trends were identified. Enhanced quality assurance could have enabled greater consistency and the identification of learning points.
Opt-out testing for blood-borne viruses was offered with good uptake and arrangements were well advanced for seasonal influenza vaccinations. National screening campaigns such as AAA and bowel cancer were delivered and prisoners were able to access smoking cessation support on arrival. A community sexual health specialist supported prisoners at a weekly clinic. Barrier protection was available from wing treatment rooms and the health care centre. Arrangements to manage outbreaks of communicable diseases had been effectively tested since the last inspection.
Prisoners received an initial, comprehensive health screen and onward referral for additional support if required. Reception staff could access community records via the NHS Spine. A RMN nurse completed a secondary well-man screening within 7 days, and completion rates had improved significantly since the last inspection to more than 90% in the first quarter of 2019 to 2020.
GP’s ran daily clinics from Monday to Saturday, with routine appointments available in less than 10 days and daily emergency slots. Staff could access out-of-hours advice through the national 111 system.
Administrative staff managed health appointment applications, which could be requested via electronic kiosks on the wing. DNA rates were too high for several clinics, particularly GP clinics, which averaged 40% non-attendance between May and July 2019. Health care managers analysed the reasons for non-attendance and had worked with the prison to try to address any barriers. Recent changes had included increased prisoner movement, and a drop-in clinic at prisoner activities.
Long-term health conditions management was very good and reflected national guidance. Need was appropriately identified and a specialist nurse ran daily clinics and promptly reviewed all prisoners with an identified condition. Patients were involved in developing their own care plans.
External hospital appointments were well managed and clinical input ensured that urgent appointments went ahead. The reasons for cancellations were reviewed regularly and too many appointments were cancelled because of late attendance.
The 26-bed inpatient unit was full at the time of the inspection, with 3 patients awaiting admission. Well-led custody staff and nurses met each day to plan care and delivered a consistent and enabling environment which was no longer used for non-clinical purposes.
The regime had been radically transformed and was unrecognisable from what was seen in 2017. Most patients were unlocked for the majority of the day and had access to an extensive regime enabling them to freely associate in the pleasant dayroom, which had a library, television and games equipment. Teachers visited patients who could not attend education.
At the time of the inspection, 2 prisoners were receiving extensive personal care packages in the inpatient area as this could not be accommodated on the wings. The prison had completed an audit of capability and there was a credible plan to equip one cell on each wing to a standard more suited to social care. Inspectors were told that no category C prisons had been identified which could deliver care to those re-categorised prisoners requiring extensive social-personal care.
In the survey, 50% of prisoners said they had mental health problems and 61% against the comparator of 34% said they had received help. It was observed that mental health services had been transformed since 2017.
The integrated mental health team had been expanded to include a wide range of clinicians including cognitive therapists, counsellors, learning disability nurses, mental health nurses, occupational therapists, forensic psychiatrists and a social worker. The nurses delivered a 7-day service within a strong multidisciplinary working model, and they were no longer diverted to other duties.
There was a robust approach to the identification of prisoners with mental health or learning disability conditions. The reception health screen for new prisoners contained mental health, learning disability and neurological components. Impressively, all new prisoners were offered a wellbeing mental health interview within 3–4 days of arrival and all new SystmOne records were screened by learning disability nurses to identify indicators of vulnerability. Mental health nurses offered weekly ‘drop-in’ sessions on each wing to ensure access for prisoners requiring advice and support and learning disability nurses used the north-west individual risk mitigation profile. Both these initiatives were innovative in the prison.
Mental health and learning disability nurses attended safer custody meetings and ACCT reviews to coordinate activities. Mental health nurses also contributed to segregation reviews.
About 45% of the population were being monitored by learning disability and mental health workers at any one time, with about 200 in regular therapy. The average time to see a psychiatrist for a non-urgent appointment had improved and was now 3 weeks compared to the 10 weeks in 2017.
80% of custody staff had received mental health awareness training which had resulted in more appropriate referrals. Mental health nurses led reflective practice sessions for custody officers in the wellbeing and inpatient units, which the officers valued.
Clinical support for prisoners arriving with substance use problems was good. Reception GPs prescribed medicines for detoxification and substance use dependence, and a substance use GP and/or clinical lead conducted a full clinical review the following day. All patients receiving treatment were reviewed again after 5 days and at 13 weeks by clinical and recovery staff.
At the time of the inspection, 125 patients were receiving methadone and buprenorphine or chlordiazepoxide with prescribing noted as being flexible and based on national clinical guidance.
Early days observation of patients stabilising on methadone and detoxing from alcohol had improved since 2017. New hatches had been installed on the drug treatment unit (A wing), which enabled improved observations, and 24-hour observations by health staff were embedded in practice. Prisoners who were stabilising or detoxing were not always located on A wing or the inpatient unit, but they all received regular observations.
Access to psychosocial interventions had improved significantly, despite continuing high demand. Prisoners received harm reduction advice during induction, and new referrals were seen within 3 days. At the time of the inspection, the recovery service was supporting 311 prisoners (45% of the population), delivering flexible, wide-ranging individual and group interventions before release. All patients could access regular mutual aid groups and support from accredited peer workers.
In-possession medication was supplied by the community pharmacy as patient named items, which were appropriately labelled. However, these medicines were not always promptly received causing short delays in some non-essential medication.
Nurses and pharmacy technicians administered medication 3 times a day from wing treatment rooms. Sedatives and night doses could be administered by night nurses. Officers generally supervised the administration of medicines well, but some treatment rooms opened up directly onto the wings and queues were not always fully supervised by officers. This compromised confidentiality and increased the risk of diversion.
Most patients received their medication appropriately. However, some patients had to choose whether to attend work or collect medicines, and other patients who were unlocked late and were delayed in receiving their medicines. Prisoners did not have access to pharmacy-led clinics, but there were plans to start clinics for new medicines, medicine use reviews and over-the-counter medicines.
A treatment room that served 2 wings was found to be wholly inadequate. It was too small, with not enough bench and storage space and restricted viewing areas for observing patients.
As part of the survey, 54% 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:
- All wing treatment areas should comply with infection control and prevention standards and should have sufficient, secure storage space for medicines and other equipment.
- Recipients of social care who are re-categorised should not be prevented from progressing from category B prisons because of a lack of appropriate social care provision at category C prisons.
- Patients requiring admission to secure mental hospitals should be transferred expeditiously and within the current guidelines.
- The level of support provided by prison officers during the administration and collection of medication should be enhanced to minimise potential bullying and diversion of supplies.
Good Practice: Health, Well-being and Social Care:
- The potential for failing to identify prisoners with vulnerabilities was significantly reduced by innovative initiatives: mental health wellbeing reviews, drop-in clinics on the wings, and case-record reviews by learning disability nurses for every new prisoner following reception.
CQC Requirement Notices Issued: