“More needed to be done to understand and analyse what sat behind the increase in self-harm. The number of prisoners subject to assessment and care procedures because of the perceived risk they posed to themselves was in danger of becoming so great as to be unmanageable.” – Peter Clarke
This report was on an unannounced inspection of HMP & YOI Doncaster between 09–20 September 2019, and was published in January 2020.
General Points of Interest:
About 30% of the population was under the age of 25.
63% of prisoners had stayed at the prison for 6 months or less.
The number of self-harm incidents had increased and was higher than at similar prisons. 52% of prisoners had been assessed as presenting a high risk of harm.
There had been 5 self-inflicted deaths in the past year, and a further suspected self-inflicted death shortly after the inspection.
Healthy Prison Outcomes:
|Rehabilitation & Release Planning||2||3|
|Rating||Outcomes for Prisoners|
|2||Not Sufficiently Good|
Key Points of Interest: Health, Well-being and Social Care:
There was observed evidence of good partnership working between health services and prison staff at management and operational levels. Overall, health services had improved since the previous inspection.
Funding bids for improving mental health provision had been submitted to NHS England as a result of the recent Health and Social Care Needs Assessment.
There were good local governance arrangements, with embedded quality assurance processes and a reflective learning culture. Regular patient consultations and surveys informed service development.
Incident reporting was used to improve patient care, with 139 incidents reported and investigated in the previous 6 months. Over 125 concerns had been submitted in this same period, with only 2 concerns having been escalated to a formal complaint. Many concerns were about prescribing, gaps in the provision of prescribed medicines, or access to mental health services.
Registered nurses were readily available 24 hours per day. Staffing levels remained a challenge, with ongoing recruitment to fill vacancies in primary and mental health nursing and the pharmacy. Staff were well supported, with excellent access to training opportunities, and embedded reflective support and supervision.
The healthcare centre was clean. There were 3 treatment rooms on the wings that did not have sinks and were therefore used for limited prisoner care. There were credible plans to upgrade the health care facilities on the wings, with the intent to provide additional space for wing triage and clinics. Infection prevention and control arrangements were good.
Health promotion was effective and well coordinated. A calendar of well-supported events reflecting national programmes had been established. Health information and posters were evident throughout the prison. Smoking cessation support was well promoted.
Prisoners were screened by a nurse on arrival at reception, and NHS community summary care records could now be accessed, which enabled continuity of care in most cases.
Secondary health assessment appointments were made following screening, although attendance was variable. Weekly complex care meetings and improved quality assurance processes identified patients at risk, and health needs were prioritised – an improvement since the previous inspection. Prisoner attendance at healthcare appointments was low, with a DNA rate of around 25%.
Waiting times for primary care services were equivalent to those in the community. Careful attention was paid to the oversight and monitoring of patients with pain management and drug-seeking concerns, which enabled a consistent approach.
GPs provided surgeries during weekdays and supported advanced nurse practitioners (ANPs), who delivered minor injury and illness clinics, and long-term condition care. Prisoners with long-term conditions were regularly invited for reviews, where they received health and lifestyle information and encouragement to adopt healthier personal choices.
There remained a high need for external hospital appointments (over 900 had been requested in the previous 6 months). The number of escorts currently available (5 per day) was considered insufficient – approx 30% of clinically required external appointments could not be facilitated by the prison.
X-ray and ultrasound scanning took place within the prison twice a month, and access to telemedicine appointments via Airedale Hospital were also available. This reduced some demand on external hospital escorts, and there was direct telephone access to hospital consultants for specialist advice.
Several social carers provided care to 15 prisoners at the time of the inspection. Most of these required substantial assistance with mobility and personal care needs, the majority of whom resided on the social care unit (SCU). However, the regime and available care were negatively affected by short-notice changes to officer allocation, and social carers having to leave the unit to help with medications elsewhere.
A small, well-led team of committed and experienced nurses delivered a mental health service 7-days a week. However, the staffing profile was not able to meet fully the high demand, with over 200 patients on the current caseload. At the time of the inspection, there were 3 nursing vacancies and 3 other posts covered by regular agency staff, with other vacancies in counselling and psychological therapies.
All routine MH referrals were triaged and allocated by the clinical matron for initial assessment on the day, or within 24 hours, by a dedicated duty worker, who also attended all ACCT case management initiations. Routine assessments generally occurred within a week following triage, but there were some inconsistencies, and as a result gaps in appointments could occur, causing frustrations for patients.
Good input and oversight by the psychiatrist mitigated risk but, unlike at the time of the previous inspection, there was no group work, clinical psychology, low-intensity improving access to psychological therapies provision, or counselling available.
Some aspects of governance, such as supervision and audit, were inconsistent, and few officers had received any mental health awareness training.
Substance Misuse Service staffing levels had been increased, enabling the range of individual and group psychosocial support activities to be expanded to meet the high demand. The team was appropriately focused on prompt assessments, risk management and treatment. It also provided a ‘well man’ interview for every new prisoner. The recovery unit lacked a recovery ethos and regime, although thought was being given to improving support for abstaining prisoners.
Clinical prescribing was flexible, and informed by 5-day and 13-week joint reviews, which occurred consistently. First night prescribing was provided in response to urgent needs. Around 200 patients were in receipt of opiate substitution therapy at any one time, with 95% receiving methadone, of whom up to 25% were appropriately on reducing regimes as most of them needed stabilisation. A large number of patients (235 in the previous 6 months) needed alcohol withdrawal treatment, which was safely managed, as registered nurses now observed patients on the stabilisation unit throughout 24 hours.
Medicines were received from an off-site pharmacy against legally valid prescriptions faxed to the pharmacy. Most medicines ordered before 11.30am were received on the same day. However, one patient was observed not to have received his medicines, despite having been in the prison for one week. Staff had told him that the medicines had been sent to another establishment in error, but showed no urgency in retrieving them. There were persistent complaints by patients about their medicines being delayed when they first arrived at the establishment, or after reordering their medicines.
Not-in-possession medicines were administered safely from the wings 3 times daily by pharmacy technicians or nurses, with additional provision for night-time administration by nurses. The interactions observed were good, but follow-up on non-attendance for medicines administration was not audited robustly. Medicines queues were adequately supervised by officers, but sometimes there were insufficient officers in attendance due to the volume of patients queuing for medicines.
About 65% of medicines were given to patients in-possession. There was an in-possession policy, with regular risk assessments and reviews, although the reasons for decisions were not always recorded. In-possession medicines were correctly supplied as patient-named items, with individual labelling and a dispensing audit trail. A few patients were provided with medicines in multi-compartment compliance packs, which demonstrated personalised care. Prisoners had access to medicine use reviews, and the pharmacy contributed to monthly patient risk meetings.
Prisoners were given an adequate amount of medication on planned discharge, or provision was made for them to obtain medication in the community. However, the lack of provision of medications following unplanned discharge from court continued to be an issue.
The storage of medicines requiring refrigeration was not adequate. Maximum and minimum refrigerator temperatures were recorded, but inconsistently, and no actions were taken when the required range was exceeded.
As part of the survey, 43% of prisoners rated the overall quality of the health services as being either very good or quite good.
The CQC issued one Requirement Notice against Regulation Standards.
Recommendations: Health, Well-being and Social Care:
- Mental health services should provide timely, stepped care support through an appropriate range of therapeutic interventions that is sufficiently resourced to meet the high level of demand.
- Patients should receive prescribed medicines without delay, and effective monitoring procedures should assure the integrity of stored medicines.
- Patients should attend health care appointments inside the prison and externally, as advised by clinicians.
- Patients requiring admission to hospital under the Mental Health Act should be transferred expeditiously, and within current Department of Health guidelines.
- There should be sufficient professional pharmacy presence to ensure efficient medicines delivery systems, follow-up of patients failing to attend for medicines administration, and the monitoring of in-possession risk assessment rationales.
Good Practice: Health, Well-being and Social Care:
- The ‘well man’ interviews ensured that every prisoner had a personal needs interview, which complemented health assessments in providing an identification of health protection factors and identifying those most at risk.
CQC Requirement Notices Issued:
- Regulation 12: Safe Care and Treatment. 12(1) Care and treatment must be provided in a safe way for service users.
How the regulation was not being met:
- Assessments of the risks to the health and safety of services users of receiving care or treatment were not always carried out. In particular:
- One patient with a known history of deep vein thrombosis did not receive a timely assessment of their condition. Diagnosis and treatment were delayed for 6 days. This care did not meet NICE guidance on deep vein thrombosis management.
- There was insufficient proper and safe management of medicines. In particular:
- Despite prompt medicines reconciliation, patients did not consistently receive their medicines in a timely way on reception at the prison. One patient waited 5 days before receiving an anticoagulant used to prevent life threatening complications from deep vein thromboses.
- The integrity of some medicines could not be assured. Refrigerator and room temperatures were not being recorded in line with the provider’s policy, across several clinical areas. Where storage temperatures were consistently out of range there was no evidence that this was identified, reported or acted upon to ensure medicines remained safe for use.
Full HMIP Report – HMP & YOI Doncaster