Tag Archives: ACCT

IMB Reports: Health Notes – June 2019

Published IMB reports during June 2019 were The Mount, Leyhill, Exeter, Lindholme, Grendon, Gartree, Northumberland, Lewes and Springhill.

Here are some of the more interesting points contained within those reports, pertaining to health:

IMB Report – HMP The Mount

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • A net gain of 83 officers in 12 months, going from 110 in Feb 2018 to 193 in Feb 2019. This increase has seen a positive reduction in prison cancellations of hospital appointments.
  • An operational Wellbeing wing is providing support to prisoners with both substance misuse and mental health needs. Prisoners with more serious mental health needs are often located in CSU in the interests of either Good Order or Discipline of Own Protection.
  • Peer supporters employed as Health and Wellbeing Champions (HAWCS) provide health and wellbeing advice, guidance, brief interventions and support to fellow prisoners.
  • Healthcare applications to the IMB decreased to 7 from 21 to 7 when compared to the previous reporting year.

Full IMB Report – The Mount


IMB Report – HMP Leyhill

Reporting period – 01 Feb 2018 to 31 Jan 2019.

  • As a Cat D prison, the Healthcare service is comparable to a well-run GP practice. Greater emphasis is placed on prisoners in accepting responsibility for improving their personal health, which is commendable.
  • Perhaps going to far in trying to replicate community equivalence, the GP Clinics have reduced by 1 day per week, leading to a waiting time of approx 3 weeks. The average waiting time for new dental referrals is reported as being 10 weeks.
  • Healthcare applications to the IMB increased to 5 from 2 when compared to the previous reporting year.

Full IMB Report – Leyhill


IMB Report – HMP Exeter

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • In May 2018, HMCIP invoked the Urgent Notification protocol, which provides its own challenging backdrop for the delivery of any healthcare services.
  • HMP Exeter boasts an 11-bed social care unit (F wing) which includes a palliative care suite and a constant supervision cell.
  • The telemedicine Video-link facility is proving to be effective in enabling prisoners to have specialist consultations without the need to attend hospital, although staff report delays in the receipt of those written reports.
  • Clinics receive the support of dedicated officers although attendances/DNA’s remain heavily reliant on motivated “runners” which is typical of many prisons. DNA rates fluctuate from less than 10 for the GP/Nurse clinics to as high as 60% for services such as the physio and the optician.
  • Healthcare applications to the IMB decreased to 25 from 39 when compared to the previous reporting year.

Full IMB Report – Exeter


IMB Report – HMP Lindholme

Reporting period – 01 Feb 2018 to 31 Jan 2019

  • The recruitment of extra prison staff is welcomed. However, the low age and limited life experience of a significant proportion of new recruits has been observed. The IMB pose the question to the Minister To consider raising the minimum age of application to the Prison Service to beyond the current 18 years.
  • The IMB ask the Prison Service to consider what measures are needed to ensure that the staffing levels of the Healthcare provider are maintained as per contract.
  • Incidents of self- harm decreased in comparison to the previous year, although the data still produced a worrying picture. The monthly average of incidents was 30.7 in this reporting year, with more or less consistency throughout the year. This compared to a monthly average of 44 incidents in the previous reporting year. The large majority of incidents were by cutting and were carried out on the wings in singular cell accommodation.
  • Cosistent with the above, the number of ACCTs opened in the reporting period saw a reduction with an average 15.5 per month compared to 36 per month in the previous year.
  • There were 7 Deaths in Custody during the reporting period.
  • Healthcare staffing levels revealed that at the end of the reporting year, 16 out of a total of 60 posts were either vacant, awaiting completion of the recruitment process or subject to a period of notice. Staffing recruitment problems have been identified on the risk register. Mental health has been the most affected, and Substance Misuse Services the least.
  • Waiting Times to see a GP varied significantly from month to month. At the end of the reporting year, this was 3 weeks 4 days. The vacant ANP post had an impact on this. Waiting times for physiotherapy were 41 weeks and podiatry 19 weeks.
  • The DNA rate for prison GP appointments has reduced towards the end of this reporting year to 7%.
  • A Telemedicine service has been provided but has proved to be not as useful as hoped. This was attributed to waiting times and the rejection of referrals, and therefore diverting referrals back into mainstream secondary care.
  • Cancellation of hospital appointments by the prison was high, and at the end of the reporting year it was 10.6%.
  • Work-fitness clinics: daily clinics (Monday to Friday) to assess prisoners who felt that they were not fit for work, in the context of a working prison, have been re-established with an 80% coverage of working days. This has been a welcome development.
  • Healthcare applications to the IMB decreased to 30 from 54 when compared to the previous reporting year.

Full IMB Report – Lindholme


IMB Report – HMP Grendon

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • Incidents of self-harm for the year were 26 compared with 43 for the previous year, which included two individuals who self-harmed on multiple occasions.
  • 52 ACCT’s were opened for the year compared with 62 in 2017. Reviews monitored by the Board, including some very challenged men, showed evidence of good care and support.
  • 8 assaults were recorded in 2018 compared with nine in 2017 and no use of force.
  • Grendon has been smoke free since 2017 and there is no current funding to support nicotine (cigarette) cessation, but some residents are now looking for support to come off vaping. Healthcare are exploring options.
  • Healthcare applications to the IMB increased to 7 from 4 when compared to the previous reporting year.

Full IMB Report – Grendon


IMB Report – HMP Gartree

Reporting period – 01 Dec 2017 to 30 Nov 2018.

  • The high number of men with complex mental health needs (i.e. those on ACCT documents, self- harming, on dirty protests in the SAPU puts considerable strain on staff, who despite doing everything they can in very difficult circumstances, may not be best placed to deal with some of these more complex prisoners.
  • The Board is aware of occasions throughout the year where men in the Segregation Unit have not received prescribed medication when it is due or needed.
  • For the majority of this reporting period, responsibility for provision of the integrated healthcare services at Gartree was provided through Mitie Care & Custody (Health) Limited. On 1 November 2018, Nottinghamshire Healthcare NHS Foundation Trust (NHFT) took over the responsibility for the delivery of healthcare at Gartree.
  • The IMB continued to hold the view, as expressed in their Annual Report 2016/17 that the prison regime and the health and wellbeing services at Gartree for this reporting period were not designed or resourced to improve health and wellbeing, or tackle health inequalities and the wider determinants of health.
  • The Board acknowledged that a change in provider was appropriate, and addressing the current inadequacies of the healthcare services is critical.
  • Healthcare applications to the IMB increased to 47 from 22 when compared to the previous reporting year. In many instances healthcare applications related to the lack of response to complaints by Healthcare.

Full IMB Report – Gartree


IMB Report – HMP Northumberland

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • 2018 saw one death in custody, compared with five in each of the two previous years.
  • The IMB have previously recorded their disappointment that the deterioration in routine waiting times for both GP and dental services has not been addressed more quickly. In this reporting year, the situation remains unchanged, with waiting times for both services continuing to fluctuate throughout 2018 despite the periodic provision of additional sessions.
  • Waiting times for the GP peaked at 36 days in July and August, and reduced at the end of the year. Waiting times for dental treatment stood at 29 weeks, with a hope that this would improve in 2019.
  • Healthcare applications to the IMB decreased to 38 from 46 when compared to the previous reporting year.

Full IMB Report – Northumberland


IMB Report – HMP Lewes

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The Board is concerned about the safety of men in HMP Lewes. In the reporting year, recorded incidents of violence perpetrated by a prisoner on another prisoner rose from 165 to 278, an increase of 68%.
  • There have been five deaths in the reporting year. Over the last year 579 ACCT documents have been opened.
  • The Board has found that for much of the reporting year the delivery of healthcare services has suffered from staff shortages and poor process and communications which have significantly impacted on the care provided for prisoners.
  • The Board has found that waiting lists for routine GP and dentist appointments have been unacceptably long at various times: in the six months May-October the wait to see a GP was an average of 12 weeks, and in June and January, the waiting time for the dentist was 10–12 weeks. In addition, the integrated mental health team typically had in excess of 50 residents waiting for an assessment appointment, with some men waiting many months to be seen.
  • The Board considers that the complaint management process remains poor and provides little opportunity for an overarching view of healthcare delivery. Each service provider manages their own complaints, and the quality of responses and the integrity of the data is variable. There were typically 20–30 complaints a month to the two main providers and the consistent themes throughout the year were access and waiting times, and not getting the medication wanted.
  • The prison went smoke-free in April 2018, and a programme implemented by the pharmacy team supported by gym officers ensured that the transition went smoothly. The smoking cessation activity has continued, with 220–240 men supported each month. Feedback from participants of programmes run by Forward Trust (alcohol and substance misuse) was excellent.
  • Healthcare applications to the IMB increased to 72 from 50 when compared to the previous reporting year.

Full IMB Report – Lewes


IMB Report – HMP Springhill

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • HMP Springhill is jointly managed with HMP Grendon (located next door). A single Independent Monitoring Board monitors both prisons.
  • Opened ACCTs remain low at 5 for the year. It is a good indication that the prison has the confidence in care to be able to support men on ACCTs. There were no reported incidents of self harm for the entire reporting period.
  • Pregabalin appears to be the drug of choice over Spice/NPS (new psychoactive substances). Cannabis has also been more prevalent, which might account for the overall 46% increase in positive test results compared with 2017.
  • Healthcare staffing recruitment has proved challenging when striving for a full complement of staff during the year, and in particular to fill the post of pharmacy technician. Staff have been faxing scripts for validation to pharmacy staff at other prisons in the region, causing occasional delays in men getting their prescriptions at weekends.
  • There are currently no healthcare meetings with residents, but this is being addressed.
  • Dental services have made significant progress in ensuring that all new patients are seen within the prescribed time. Residents positively rate dental care.
  • Healthcare applications to the IMB decreased to 0 from 6 when compared to the previous reporting year.

Full IMB Report – Springhill


HMIP Report: HMP & YOI Foston Hall, Feb 2019 – Health Summary

This report was on an unannounced inspection of HMP/YOI Foston Hall between 04–15 February 2019, and was published 19 June 2019.

General Points of Note.

There had been two self-inflicted deaths since the previous inspection. Not all Prisons and Probation Ombudsman recommendations had been implemented in full.

Incidents of self-harm were very high and significantly higher than at similar prisons. A total of 900 self-harm incidents had occurred in the six months prior to the inspection, 52% of which were attributed to six individual prisoners with complex issues.

More than 300 assessment, care in custody and teamwork (ACCT) case management documents for prisoners at risk of suicide or self-harm were opened in the six months prior to the inspection, which was higher than at similar prisons. The ACCT documentation we examined showed some good practice and improvements, including regular case reviews and better attendance by health care staff. Care maps were limited – they were not updated regularly and were not always tailored to the prisoners’ individual needs, despite a PPO recommendation requiring these improvements.

A three-tier quality assurance process for ACCT documentation had been introduced. Although a positive initiative, it had not identified shortcomings in care maps or assessments of risk.

A new ACCT process was scheduled to be trialled for three months from mid-February 2019. The new process was more dynamic, prescriptive and holistic and included inviting family members to case reviews, which had been a previous PPO recommendation.

Healthy Prison Outcomes:

  • Safety = 3 (3)*
  • Respect = 3 (3)*
  • Purposeful Activity = 3 (2)*
  • Rehabilitation and Release Planning = 3 (3)*

Note: *(Previous inspection outcomes from June 2016 are stated in brackets)
Key:

  • 4 = Outcomes for prisoners are good.
  • 3 = Outcomes for prisoners are reasonably good.
  • 2 = Outcomes for prisoners are not sufficiently good.
  • 1 = Outcomes for prisoners are poor.

Key Points of Interest: Health, Well-Being and Social Care:

Not all clinical staff received clinical supervision, but some had received supervisor training and plans were in place to support the implementation of clinical supervision. Access to additional training was good and covered trafficking, sex working and domestic violence.

All prisoners had good access to health care services. Clinical space was limited, but the team used it effectively. All clinical areas were clean and well equipped, but there were no cleaning schedules.

Health care complaints were placed in boxes opened by PID workers, which meant they were not confidential. However, this practice stopped during the inspection. All concerns and complaints were dealt with face to face at a weekly clinic held by a senior manager. Issues that could not be addressed at this level were escalated. Responses to concerns and complaints were appropriate and timely. Analysis took place and trends were routinely discussed at regular governance meetings.

Health and well-being champions (peer workers) also saw prisoners in reception, asked health-related questions and made referrals to health and social care services. This breached prisoners’ confidentiality and the provider ended this practice during the inspection.

The introduction of telemedicine was a welcome development.

Medicines management had improved significantly since our previous inspection. Close links with the pharmacist at HMP Dovegate meant that advice and support was readily available in addition to the assistance provided by the medicine supplier.

The management of in-possession medication had improved. The senior pharmacy technician ran a weekly in-possession risk assessment clinic; 97% of prisoners had a completed risk assessment and 57% could keep their medication with them. At our previous inspection, the figure was less than 25%.

Prisoners requiring medication in the evening received a daily in-possession dose, or evening duty health care staff gave them their medication before they left the prison. A policy was now in place to ensure pain medication was available overnight if required.

In our survey, 74% of prisoners reported having a mental health problem and 54% of them said they had received help while at Foston Hall.

The integrated mental health team provided a service six days a week. The team was able to meet the needs of the population. With an average of 65 referrals a month, 37 patients were on the primary caseload, and 43 on the secondary caseload. This included 11 patients treated under the care programme approach (CPA).

Mental health practitioners held a daily meeting to discuss the allocation of all new referrals and consider any urgent patient issues.

Care UK provided the prison with a mental health worker to co-facilitate a mental health treatment programme Conquering Anxiety and Low Mood for prisoners with mental health needs.

The mental health team allocated a duty worker who attended all daily ACCT case management reviews for prisoners at risk of suicide or self-harm who were related to caseloads, or who were new in the prison, or in the segregation unit. All staff had clinical supervision and used multidisciplinary team meetings to discuss lessons learnt from ACCT reviews.

Care UK and Inclusion delivered the integrated substance use service. One third of the population was involved with Inclusion, which provided a good range of appropriate psychosocial interventions. Eighty-two prisoners were on opiate substitution treatment. Staff undertook 24-hour monitoring and regular observations.

Care UK and Inclusion provided specialist dual diagnosis treatment for prisoners with mental health issues, which was good. Prescribing was flexible, and there was a well-attended multidisciplinary approach towards clinical and psychological treatment, which demonstrated joint working.

The CQC found there were no breaches of the relevant regulations.

Recommendations: Health, Well-Being and Social Care:

  • Cleaning schedules should be in place and monitored regularly to ensure the cleaning has been done and infection prevention standards are met.
  • All clinical staff should receive regular clinical supervision.
  • A prison-wide strategy should be established to support health and well-being, and it should include easy access to barrier protection.
  • Health-related peer worker activities should not compromise patient confidentiality.
  • The environment in which medication is administered should ensure patient confidentiality.
  • In-possession medication should not be provided in transparent bags.

Good Practice: Health, Well-Being and Social Care:

  • The weekly in-possession risk assessment clinic ensured risk assessments were completed promptly and enabled patients to discuss their medication with pharmacy staff.
  • The safer prescribing meeting meant staff could focus on how they managed prisoners’ medication, which helped improve patient care.

CQC Requirement Notices Issued:

  • None.

Links/Resources:

News Release – HMP & YOI Foston Hall

Full Report Here – HMP & YOI Foston Hall

National IMB 2017/18 Report – Prisons in ‘fragile recovery’

On the 5th June 2019, the Independant Monitoring Board (IMB) published their National Annual Report for the late 2017 to 2018 period.

The IMB findings reported on 10 key aspects of prison life:

  • Staffing
  • Drugs
  • Safety
  • Segregation
  • Accommodation
  • Property
  • Equality and Diversity
  • Health and Social Care
  • Education, work and Purposeful Activity
  • Preparation for Release

As part of the introduction to this report Dame Anne Owers sets the scene:

“…the visible decline in (prison) safety, control and the expectations of both prisoners and staff since I last visited them, as Chief Inspector of Prisons, in 2010. It is therefore welcome that additional resources have now been put into prisons, with an influx of staff, but it will take time before prisons can not only stabilise, but progress.”

Here are some of the more noteworthy takeaways from the report that impact on the general health and wellbeing of prisons and prisoners:

Staffing.

Staffing issues dominated annual reports in this period. The main theme from across the estate is the ongoing influx of new, and therefore inexperienced staff. This is further compounded by the churn as prisons struggle to retain those officers. This affects every kind of prison and every aspect of prison life: from security and safety to healthcare, activities and rehabilitation. A recognition from the IMB that cannot be understated.

Drugs.

Drugs in prison not only have a direct impact on health and on prisoners’ erratic and sometimes violent behaviour; they also undermine safety and stability by producing an alternative power structure, based on debt, bullying and intimidation of prisoners, their families and sometimes prison staff. This also impacts on already stretched healthcare services.

Safety.

In general, incidents of violence and self-harm increased, often significantly, throughout 2018. Boards attributed this to a combination of the availability of drugs (and the associated debt and bullying), the inexperience or shortage of staff, and frustration due to inactivity.

Most boards reported an increase in the number of Assessment, Care in Custody and Teamwork (ACCT) documents opened for those at risk of suicide or self-harm during the period. It is recognised within the report that this may be in part a consequence of increased vigilance, following the steep rise in suicides in preceding years.

One board reported that they were concerned that an “overly risk-averse approach” had resulted in too many ACCTs being opened, making it more difficult properly to identify and support those at serious risk of harm. Whilst this may be very true, prisons could equally be criticised for doing the opposite. Such a practice of not opening too many ACCT’s could and is often recognised at Coroners Inquests as a failing in a duty of care. This feels very much like a case of damned if you do, damned if you don’t.

Another board noted that self-harm tended to coincide with canteen day and when the prison was in patrol state (i.e. prisoners being locked in their cells). Another, recognising the same phenomenon, had produced information and distraction programmes on in-cell television, with input from mental health. Commendable indeed.

Many boards welcomed the increased staff training in suicide and self-harm, and some reported improvements as a result. However, some also pointed to continuing concerns about the quality and consistency of ACCT documentation, observations and support, and in some cases the lack of involvement by healthcare staff in ACCT reviews, especially given the strong connection between mental health issues and self-harm.

Health and Social Care.

Boards reported the pressure on prison healthcare, reflecting the level of both physical and mental health need, as well as staff shortages and the impact on prisons of shortfalls in provision outside criminal justice.

It is well known that overall prisoners’ health, both physical and mental, is worse than among the general population. Physical health outcomes are affected by lifestyles, drug and alcohol misuse and disengagement with community healthcare, as well as the complex needs of an ageing prison population.

Prisons, like the rest of the criminal justice system, disproportionately contain individuals with mental health problems, which imprisonment can exacerbate – particularly as prisons, unlike mental hospitals, cannot compulsorily treat patients except in extreme circumstances.

Many boards reported the effects of staffing shortages, both of uniformed and healthcare staff. Sometimes there were not enough uniformed staff to escort prisoners to appointments, either within the prison or to external hospitals. Staff shortages also impacted on the supervision of medication queues.

Shortages of nursing staff, particularly mental health nurses, led to long waiting times, over-high caseloads and reliance on expensive agency staff with no continuity of care.

Shortages of uniformed prison staff and poor communication also affected the high number of prisoners not attending appointments made for them (DNA’s).

The IMB report states that the underlying problem was a disconnect between the level of need and the level of provision. The demand for healthcare services, especially mental health, was extremely high in many prisons, and many boards reported that need was increasing beyond current resource.

What the report doesn’t recognise, but is equally worth noting is the demands placed on staffing resources that are compounded further – for those in need of mental health services, our prisons are recognised by the courts as being places of safety. (Feel free to pause to reflect on this for a moment.)

Conclusion.

The report provides a benchmark for the future, and it is with a sense of both hope and optimism that the array of promising intiatives already underway as part of the prison reform programme begin to reap results. Those initiatives include:

  • the roll-out of offender management in custody (OMiC)
  • the prison estate transformation programme
  • lessons learnt from the then Prisons Minister’s ten priority prisons project, and responses to the Inspectorate of Prisons’ urgent notification process
  • revised processes for supporting prisoners at risk of suicide and self-harm
  • the new drug strategy
  • embedding the CSIP (challenge, support and intervention) process for violence reduction
  • new processes and contracts for dealing with prisoners’ property.

From now on, we can also look forward to a quarterly digest of published IMB Annual Reports, as the IMB undergoes further work with Boards to identify emerging themes and issues and to record progress against the hopes and expectations of the prison reform programme.

The prison night is very much at its darkest right before the dawn.

Read the full report here

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