“At this inspection we found that outcomes had not improved in any of our tests and, of greatest concern, the prison remained poor in safety.” – Peter Clarke
This report was on an unannounced inspection of HMP & YOI Portland between 29 July to 09 August 2019, and was published in January 2020.
General Points of Interest:
Nearly two-thirds of the prison’s population were under 30 years old.
Only 11.5% of prisoners had been at Portland for a year or longer.
The level of prisoner self-harm had doubled since the previous inspection – 197 incidents during the 6 months prior to the inspection. The quality of ACCT documents were regarded as being generally poor, with some isolated areas of better practice.
Data indicated that 70% of operational prison staff had completed mental health training.
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:
Partnership working had improved recently with the allocation of a governor to liaise with health care to address longstanding issues. That said, the health service was unable to function effectively largely because the prison failed to facilitate consistent access to healthcare services.
Incident reporting data from the previous 12 months indicated that the delivery of health services had been adversely affected by a lack of officer support to enable access to services. Medication administration sessions were protracted and clinics routinely cancelled. Several inappropriate prison transfers had been made of prisoners with acute physical and mental health conditions which the health provider had to resolve. Despite escalation of these incidents to commissioners and the prison, this still prevailed at the time of the inspection.
Inspectors noted a skilled and dedicated workforce striving to deliver good care and interacting positively with patients. Staffing levels were stretched which hindered delivery of some services, although was mitigated by use of regular agency and bank staff. Additionally, the Head of Healthcare and clinical leads frequently covered any shortfalls.
Clinical supervision systems were embedded and staff felt supported. There was a high rate of compliance with mandatory training and professional development opportunities were available.
Healthcare staff handover meetings took place daily and a weekly multi-professional complex case meeting demonstrated effective working and the promotion of good standards of care.
Clinical rooms generally met infection control requirements, but the floors needed a deep clean including a treatment room. Some of the sharps boxes were not secured to the wall and some out-of-date items were found during the inspection which were then removed.
Holding rooms in the health centre remained unsuitable. One had improved but the other was stark and still had wooden bench seats which were a safety risk. Patients were locked up for too long in an overcrowded, cramped and a poorly managed area. Inspectors observed prisoners vaping in the holding room which was not challenged by officers.
A healthcare clinical forum with wing representatives was a promising initiative with ‘You said, we did’ posters displayed. In March 2019 the issue had been raised of health care appointment slips not being received. Some prisoners repeated this concern during the inspection and health staff were investigating.
Primary care staff were available from 8am to 6pm every day. They responded to emergencies and had received intermediate life support training. Automated external defibrillators (AEDs) and resuscitation equipment were strategically sited across the prison. However, out-of-date AED pads were found in reception which were replaced, and there were anomalies with the frequency of checks. A new system had recently been implemented to identify stock that needed replenishing, but more regular checks were still needed.
There was no whole-prison approach to health promotion, but a calendar of health promotion events had been developed and the recent World Hepatitis Day was well received, with 250 prisoners attending.
Health staff did not attend induction sessions for new arrivals and there was no local health information leaflet. Other health promotion literature was displayed but was not readily available in languages other than English.
Immunisations and vaccinations, NHS health checks and health checks for patients on mental health medication were offered but seldom delivered because regime restrictions prevented ready access. Smoking cessation support and nicotine replacement therapy were available but take-up was low.
Registered nurses or HCA’s conducted reception screening. The service had recently introduced an optional diagnostic test for HIV, Hepatitis B and C. Staff were observed explaining the implications of this clearly, but there were reservations about delivering a positive result at this stage rather than at the second health screening stage. The service had decided to do this at reception because of prisoners’ limited access to secondary screening.
There was a suitable range of primary care services, most of which had reasonable waiting times, and additional sessions were delivered to help reduce the waiting lists for the optician and the dentist.
The NHS England Quality and Outcomes Framework (QOF) supported the identification and monitoring of prisoners with long-term conditions. Some nurses had received additional training, but most patients were managed by the GP with regular reviews.
External hospital appointments were well managed, with few cancellations through lack of prison escort staff. Telemedicine had started to be used with positive patient feedback.
On release, patients received a GP discharge letter describing the care they had received and any continuing medication. Patients were encouraged to collect their medication before leaving but were not always brought to healthcare to collect it.
The current mental health service did not meet the service specification and was not informed by an up-to-date needs assessment. Work was in progress to develop the service and ensure that the provision reflected the service specification.
Chronic MH staff shortages limited the range of treatment options. Efforts were made to attract new staff, but recruitment was a significant challenge. The mental health team operated 5 days a week with plans to embed a 7-day service. Locum psychiatry provision was in place but the service was inconsistent.
Access to mental health services was affected by prison regime restrictions, with high DNA rates reflecting many occasions when the prison had been unable to facilitate movement to appointments. Patients were not seen on the wings for safety reasons and a lack of privacy.
A MH duty worker saw all new arrivals within 24 hours to inform them of services and identify mental health needs. There was an open referral system and triage assessments were timely. Patients presenting in crisis could be seen on the same day. New referrals and assessments were reviewed at a weekly multidisciplinary team meeting.
The MH team attended the majority of ACCT reviews and contributed to the multidisciplinary support offered to prisoners who self-harmed. Staff also supported the work of the segregation unit.
The local substance misuse strategy had been updated to reflect the national strategy. The substance misuse service contributed to monthly strategy group meetings and received referrals of prisoners testing positive or suspected of NPS use, of which there had been a noticeable decline recently (from 73 in June to 40 in July 2019).
At the time of the inspection, 160 prisoners were engaged with the service and prisoners clearly appreciated the support they received. Structured one-to-one sessions were supplemented by excellent workbooks, and the broad range of interventions included the 10-session SMART Inside Out programme, a family group, first steps to recovery, ‘Reduce the Use’ and mindfulness groups and one-day awareness workshops.
Psychosocial and clinical services were well integrated, although not co-located. The clinical substance misuse lead was a non-medical prescriber and although she was based in health care, and the poorly supervised movement of prisoners near her office gave rise to concerns for her safety. She was only available 2 days a week to assess, treat and review an average of 59 patients, which was almost a 50% increase since the last inspection.
Although methadone regimes were flexible and subject to regular joint review, it remained the only opiate substitute treatment on offer because the prison could not accommodate buprenorphine administration. Services for patients experiencing mental health and substance-related conditions remained inadequate, and there was no protocol or pathway for this patient group.
Pre-release preparation and through care arrangements were good, and bridging prescriptions of methadone were issued to ensure that treatment continued in the community. Harm reduction advice included Naloxone training to treat opiate overdose.
Repeat prescriptions were fulfilled promptly, but medicines from new prescriptions arrived up to 48 hours after the order which was frustrating for prisoners and staff.
The pharmacy technician and nurses administered medication in the health centre and on another unit at 8am and 4pm. Delays in the regime and the late arrival of patients being escorted to healthcare resulted in lengthy medicine administration times. There was a risk that a patient’s late arrival could compromise the therapeutic effectiveness of medicines. Medication queues were poorly supervised. Patients were afforded little privacy, increasing the potential for bullying and diversion of medicines.
About 60% of prisoners on prescribed medication had it in possession following appropriate risk assessment at reception which was reviewed if there was a change in circumstances.
A pharmacist now attended the prison once a week to give professional oversight to the service and was available to see patients. This was not advertised. A systematic approach was taken to the management of tradeable medicines. The pharmacist completed regular audits and liaised with prescribers and the healthcare team to review their use. Prescribing activity was monitored and discussed at regular medicine management meetings. A full range of standard operating procedures and policies were accessible to staff electronically.
Paracetamol had been taken off the canteen list for security purposes. Discussions were in progress to reinstate it on the list with governance to ensure that healthcare staff were aware of any purchase.
As part of the survey, 46% 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 should have prompt access to health services, including sufficient officers to ensure safe and timely medication administration and prompt attendance at health clinics.
- There should be a whole-prison strategy and approach to support health promotion and well-being activities.
- Prisoners with mental health conditions should have prompt access to a comprehensive range of care-planned support that meets their identified needs, including groupwork and psychologically informed interventions.
- The full range of prescribing options should be available, and prescribing decisions should be made on clinical need. (Repeated recommendation).
- There should be sufficient provision for prisoners with both mental health and substance-related conditions. (Repeated recommendation)
Good Practice: Health, Well-being and Social Care:
- Prisoners with drug and alcohol conditions and their families benefited from a designated family service which offered a range of support and focused on rebuilding healthy relationships.
CQC Requirement Notices Issued: