HMIP Health Notes: HMP Hewell, Jun 2019

This report was on an unannounced inspection of HMP Hewell between 03–14 June 2019, and was published in September 2019.

“The award of our lowest grade of ‘poor’ for safety was not a consequence so much of the actual level of violence, but more of a reflection of a range of failures to provide an environment in which prisoners could feel safe, where victims of violence would be supported, where perpetrators would be challenged and poor behaviour would lead to consistent and effective sanctions.” – Peter Clarke

General Points of Interest:

Adjudications had risen significantly from 1,584 in the 6 months before the previous inspection to 2,222 for the same period at this inspection. At the time of the inspection there were 382 adjudications that had been adjourned for up to 6 months. In addition, a further 526 were dismissed or not proceeded with in the previous 6 months.

Use of force on the closed site has increased from 178 incidents at the previous inspection to 497 in the previous 6 months. Governance of use of force incidents was weak and there was too much missing paperwork, and at the time of the inspection there were 350 missing use of force documents.

Self-harm incidents at the closed site had increased from 209 in the 6 months before the previous inspection to 350 in the same period this time. The number of ACCT documents opened had also increased from 517 in the 6 months before the previous inspection to 533 in the same period before the current one. The number of open ACCTs during the inspection was high with over 60 prisoners, 7% of the population, receiving at least hourly observational checks by staff.

Since the last inspection in August 2016 there had been 4 drug-related deaths, 2 self-inflicted deaths and 1 manslaughter on the closed site. There had been no deaths in custody on the open site.

Healthy Prison Outcomes (HMP Hewell Closed Site):

2016 2019
Safety 1 1
Respect 2 2
Purposeful Activity 3 1
Rehabilitation & Release Planning 3 2

Healthy Prison Outcomes (HMP Hewell Open Site):

2016 2019
Safety 4 4
Respect 3 2
Purposeful Activity 3 1
Rehabilitation & Release Planning 3 1

Outcome Ratings:

Rating Outcomes for Prisoners
4 Good
3 Reasonably Good
2 Not Sufficiently Good
1 Poor

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

Prisoner council meetings had restarted one week before the inspection, the patient forum had recently recommenced, and patient feedback was gathered and analysed following health appointments.

Staff supervision was not provided in line with the health providers policies. There was no clinical supervision for staff.

Health complaints were managed well with the recent introduction of quality assurance, but face-to-face resolution was limited.

The health care department was a learning environment for nursing students and trainee paramedics from Worcester and Staffordshire universities.

Infection prevention and control had improved since the last visit. Most clinical rooms had cleaning schedules, but these were not always consistent in high-use rooms and some lacked prison contract cleaning. Although there were clinical audits continuous improvements remained outstanding.

Health and well-being information was available throughout the prison, and monthly national health campaigns were widely advertised and followed. There were robust systems and policies to prevent and manage communicable diseases.

9 prisoner health care ‘champions’ were supporting health care staff in the delivery of well-being advice and management. Those inspectors spoke to felt valued and well supported in their role, and received appropriate training.

The well-led and skilled primary care team offered an improved service since the last inspection, with shorter waiting times for appointments with nurses and GPs. There was good practice in the management of the very high levels of blood-borne viruses.

All new arrivals received a comprehensive initial health screening by a registered nurse, who reviewed risks and made onward referrals. A GP or nurse prescriber was available during the evening for complex cases, although late arrivals often missed out on this provision, causing prescribing delays. An additional nurse had been deployed to help screen new arrivals, but only 24% of newly arrived prisoners received secondary health screening. Secondary screenings were being cancelled due to lack of rooms.

External hospital appointments were managed well. Although some appointments had been cancelled to facilitate the large number of emergency admissions, the number that had breached the NHS 18-week rule for non-urgent consultant treatment had been minimal in recent months.

Clinical information flows for patients had improved when attending the local hospital emergency unit for urgent care. An alternative pathway had been developed for patients with long-term conditions, although work was ongoing to ensure that all these patients were receiving care in line with National Institute for Health and Care Excellence (NICE) guidance.

The 18-bed inpatient facility delivered positive outcomes for patients, despite the lack of permanent staff and living conditions that continued to be extremely poor. There were squalid cells with filthy drainage guttering outside each cell, leaking toilets and poor ventilation, resulting in the unit smelling strongly of urine. There was now a positive regime with most inpatients unlocked for a proportion of the morning and afternoon, although they still had to eat inside their squalid cells. Prison officers were not always available for the unit, leaving nursing staff to monitor at-risk inpatients with no cell keys.

5 prisoners were currently awaiting referrals to social care, of which 2 had waited over 2 months. There was no formal peer support or buddy scheme, which meant that support for prisoners with low-level social care needs was informal and not supervised or monitored.

Mental health provision had improved through investment in the service, recruitment and introducing a stepped care model for mental health support.

The integrated mental health service used group rooms, but vulnerable prisoners had limited access to group sessions. There were insufficient interview rooms for meaningful therapeutic interventions.

The recent introduction of a duty professional role had improved the initial assessment and allocation of prisoners to the appropriate level of support. There were 150 prisoners on the caseload during the inspection, 44 of whom were on the Care Programme Approach (CPA). Staff were allocated to attend ACCT case management reviews for prisoners at risk of suicide or self-harm, although late notice of the reviews affected attendance.

A range of self-help material was given to prisoners with low to moderate needs. There were health checks for prisoners prescribed mental health medicines.

Not all mental health team staff had completed their mandatory training in basic life support, safeguarding, infection prevention, fire safety etc. Caseload supervision ensured mental health care met individual prisoners’ needs.

The MH service had identified and assessed 18 prisoners for transfer to secure mental health hospitals in the last 6 months. The average wait for transfer was 80 days. While some of these prisoners were accommodated in the inpatient unit, others were held in the segregation unit due to behavioural problems; this was not an appropriate environment for prisoners with severe mental health problems.

Drug strategy meetings focused on reporting individual actions rather than taking a strategic approach to demand and supply reduction. However, the mental health and clinical substance use needs assessment had led to recent significant increases in the psychosocial provision. This was not yet matched by clinical substance use staffing, despite ongoing recruitment.

There were currently 199 prisoners on opiate substitution treatment (OST) and 333 on the psychosocial caseload.

A GP or non-medical prescriber saw new arrivals if they had a substance use problem. However, if prisoners arrived late on a Saturday and needed detoxification or stabilisation they might not be prescribed medicines until Monday, which was unacceptable.

There were no arrangements for overnight observations of any prisoner prescribed alcohol detoxification, which created significant risk. Monitoring of patients prescribed substitute and stabilisation medicines often did not take place due to insufficient clinical staff.

Inspectors observed supportive interactions with prisoners but administration of medicines was not confidential. Methadone and buprenorphine were prescribed appropriately. Prescribing reviews took place throughout the week, with one GP session and 6 non-medical prescriber sessions for substance use prescribing. There were no audits or reviews of prescribing.

Prisoners received most medicines via prescriptions. Health services staff could also administer and/or supply an appropriate range of medicines without a prescription through an authorised process. However, there were no records of staff trained and authorised to administer medicines without a prescription.

Custody Officer supervision of medicines queues had improved, although medication administration in the segregation unit was unsafe – this was rectified during the inspection.

Nurses, paramedics and pharmacy technicians administered medicines. Staff told inspectors that they followed up missed doses after the 3rd missed dose, and more quickly for critical medicines.

The medicines reconciliation rate was 20% within 72 hours and 40% in total, meaning that 60% of prisoners had not had their medicines reconciled during their detention. Staff also told us there were no specific processes to identify or prioritise prisoners with high-risk medical conditions or medicines.

At the time of the inspection, 63% of prescribed medicines were supplied in possession. Highly tradable medicines were administered only as supervised doses. Most prisoners had signed a compact agreement at reception and had an in-possession risk assessment. The monitoring of in-possession medicines was reactive and intelligence-driven, and they were not reviewed regularly.

Dental treatment and oral hygiene advice was available 5-days a week and was sufficient to meet prisoner needs. Waiting times during the inspection were around 2 weeks. Same or next day appointments were available for prisoners requiring urgent treatment, following clinical triage. 4 dental nurses and 2 dentists were in post, and there was good clinical oversight of the waiting list. The dental surgery was clean, well ordered and well maintained, and met infection prevention control requirements. Clinical governance of the dental service was robust, and staff received appropriate training and support. The surgery had access to interpreting services for non-English speaking patients.

As part of the survey, 29% of prisoners rated the overall quality of the health services as being either very good or quite good.

The CQC issued 3 Requirement Notice against Regulation Standards.

Recommendations: Health, Well-Being and Social Care:

  • There should be a joint local operating procedure to optimise emergency response, including automated external defibrillation accessible for each house block and working area.
  • Clinical supervision should be provided and recorded for all clinical staff, and mandatory training requirements should be fulfilled.
  • Social care arrangements should meet the needs of all prisoners and the requirements of the Health and Social Care Act 2014.
  • Transfers under the Mental Health Act should occur expeditiously and within the current Department of Health transfer time guidelines.
  • Prisoners with substance use needs should receive substitution treatment in line with national guidance, and monitoring should ensure that their care is safe.
  • New arrivals should receive their prescribed medicines promptly.
  • The governance of medicines optimisation should ensure the competency of staff, and the monitoring and auditing of the effectiveness of the use of medicines.

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

  • The management of the high numbers of patients with blood-borne viruses was commendable, given the high turnover of prisoners. The system for ensuring effective patient information flow to and from the local emergency unit was improving continuity of care and patient outcomes.

CQC Requirement Notices Issued:

  • Regulation 12: Safe Care and Treatment.
    How the regulation was not being met:
    The provider had not ensured that all risks to patients were assessed and appropriate action taken to reduce these risks.
    The registered person did not have arrangements in place to fully assess and monitor the risks of patients requiring alcohol detoxification.
  1. Patients receiving alcohol detoxification treatment were not monitored by health care staff overnight for withdrawal symptoms or seizures.
  2. In April and May 2019, 62 patients were prescribed medicine for alcohol detoxification and withdrawal support. No overnight monitoring of these patients took place.
  3. The 62 patients who were prescribed alcohol detoxification medicine during April and May did not receive regular or consistent monitoring by suitably trained staff.
  • Regulation 17: Good Governance
    How the regulation was not being met:
    The registered person did not establish and operate effective systems and processes to assess and monitor the quality and safety of the service. The provider’s systems and oversight of the service had not identified all risks to patients:
  1. The provider had not identified the risks associated with the absence of appropriate monitoring of patients with substance misuse needs who were prescribed medicines for stabilisation and withdrawal.
  2. At the time of the inspection, monitoring of the contents of the emergency bags did not ensure that the expiry date of glucagon was amended when removed from refrigerated storage.
  3. Records were not maintained of staff trained and authorised to administer medicines without prescriptions.
  • Regulation 18 Staffing
    How the regulation was not being met:
    Staff had not been supported by regular supervision in line with the provider’s own policy.
  1. Out of 48 staff, 16 had not received any supervision in 2019.
  2. One member of staff who was employed for three months in 2019 had left having not received supervision.
  3. A new member of staff had not received their first supervision for four months.
  4. Mental health and psychosocial staff who worked at HMP Hewell had not had access to the electronic staff record system to complete their mandatory training.
  5. The overall mandatory training compliance on 14 June 2019 was 54.74%.

Links/Resources:

Full Report Here – HMP Hewell

HMIP Report – Health Summary: HMP & YOI New Hall, Feb-Mar 2019

This report was on an unannounced inspection of HMP & YOI New Hall between 25 February to 08 March 2019, and was published in June 2019.

General Points of Note.

48% of prisoners were reported to have committed their offence to support the drug use of someone else.

Of those using the counselling service, 53% of prisoners said they had suffered domestic violence and 44% said they had been raped.

78% of prisoners disclosed they had a mental health problem, and 71% of the population were receiving services from the substance use psychosocial team.

There had been 3 self-inflicted deaths since the last inspection in June 2015.

There had been 359 incidents of self-harm in the six months prior to the inspection. This figure was higher than at the previous inspection but lower than in other women’s prisons. On average, the data identified four prisoners each month as prolific self- harmers, carrying out five or more incidents. In the six-month period before the inspection, prisoners who often self-harmed accounted for 46% of all self-harm incidents.

There had been 419 ACCTs opened in the six months before the inspection. This was higher than the time of the last inspection and comparable with other women’s prisons. A new ACCT case management system had been introduced and all those subject to the process now had a named case manager in their residential unit. The majority of care maps included targets and specific action, although too many daily entries were purely observational and lacked any detail of staff interactions.

Healthy Prison Outcomes:

  • Safety = 4 (4)*
  • Respect = 3 (4)*
  • Purposeful Activity = 3 (4)*
  • Rehabilitation and Release Planning = 4 (3)*

Note: *(Previous inspection outcomes from June 2015 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:

Many aspects of health care remained good, but significant staff vacancies in the mental health team had had a negative impact on the delivery of mental health services.

The confidential health complaints process was well promoted. Concerns were usually resolved in person, while complex complaints were escalated to managers for investigation. Responses we reviewed were generally prompt, although the outcome and action taken were not recorded consistently enough.

Monthly patient forums, together with an analysis of patient satisfaction surveys, had led to some service improvements. However, some issues had been raised repeatedly without being properly resolved.

Effective joint working was demonstrated through a range of meetings, including weekly complex case reviews and a daily handover attended by representatives from all teams identified any clinical concerns.

Clinical and managerial supervision was not provided or taken up consistently across the teams. Mandatory training was well managed and there were excellent professional development opportunities, particularly in the primary care team.

The waiting area in the health centre had been extended and it was now bright and welcoming. The lack of free-flow movement, meant that patients waited too long before and after appointments, which discouraged prisoners from attending.

Work was in progress to reduce the high non-attendance rate. Delays in prisoners receiving appointment slips had resulted in missed appointments, although a new initiative was being trialled – it involved the health care representative delivering appointment slips in sealed envelopes.

The waiting time for a routine GP appointment was over three weeks, which was too long. Urgent on-the-day appointments were prioritised by clinical need.

78% of prisoners reported having a mental health problem and 44% stated that they had received help for it while in the prison.

The MH service had deteriorated since the previous inspection, and was compounded by significant staffing shortages – five of nine clinical roles were vacant. It had also experienced a high staff turnover in recent months. The service used regular agency workers to cover some staffing gaps.

Prisoners with mild to moderate mental health issues did not have access to community equivalent, planned ongoing treatment or psychological interventions. Prisoners with more serious mental health problems received a better level of support – there was evidence of some helpful one-to-one work, informed by personal care plans and risk assessments.

In the 12 months prior to the inspection, more than 90% of prison officers had received trauma-informed training (to enable them to consider the trauma prisoners may have experienced in their lives).

The Drug & Alcohol Recovery Team (DART) was supporting 282 prisoners (about 71% of the population) during the inspection and about 170 (43% of the population) were receiving opiate substitution therapy,

The CQC issued one Requirement Notice against Regulation Standards.

Recommendations: Health, Well-Being and Social Care:

  • All health care staff should receive regular clinical and managerial supervision.
  • The non-attendance rates for all clinics should continue to be investigated and reduced,
    including a review of the applications process to see if this is hindering attendance.
  • Immunisations and vaccinations should be available to eligible prisoners in line with national programmes. They should be implemented promptly to promote prisoners’ health.
  • Routine waiting times to see the GP should be reduced and should not exceed two weeks.
  • The out of hours’ medicines cupboard and drug refrigerators should be robustly monitored to ensure medication is appropriately and safely stored.
  • The prison should ensure the process for transporting dental tools across the prison is safe.
  • Transfers under the Mental Health Act should occur within current Department of Health transfer time guidelines.

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

  • None identified/reported.

CQC Requirement Notices Issued:

  • Regulation 9. Person-Centred care. Prisoners requiring mental health support did not always receive person centred care that was appropriate, met their needs and reflected their preferences.

Links/Resources:

Full Report Here – HMP & YOI New Hall


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

This report was on an unannounced inspection of HMP/YOI Moorland between 11–21 February 2019, and was published 11 June 2019.

General Points of Note.

Levels of violence had not only stabilised, but had actually decreased, which was noted as bucking the national trend over that period. However, despite this overall reduction, assaults against staff had doubled and were higher than at similar prisons.

Use of force by staff had increased since the last inspection, consistent with the levels at other category C prisons. There had been 202 uses in the six months leading up to the inspection, compared with 110 uses in the same period before the previous inspection.

Levels of NPS use had decreased since the last inspection. drug testing positive rate was 15%, including the positive rate for NPS, which on its own was 11%.

Self-harm was described as being “very high” and these levels were reported as being 50% higher than the average for category C prisons. In the previous six months, there had been 423 incidents of self-harm, involving 195 prisoners.

The quality of assessment, care in custody and teamwork (ACCT) case management for prisoners at risk of suicide or self-harm was considered to be mostly good, and staff training and quality assurance were driving improvement in care. Assessments were consistently good, and mental health workers regularly attended case reviews.

The most serious concern for inspectors was the lack of effective public protection measures. Over half the population, 530 men, were assessed as presenting a high risk and about a third were convicted sex offenders.

Healthy Prison Outcomes:

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

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

Key:

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

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

Leadership and accountability arrangements were considered as being robust. A culture of reporting serious untoward incidents and of learning from them was established, including learning from Prisons and Probation Ombudsman recommendations. Prisoner health representatives were now in place on most house blocks, and inspectors saw evidence of consultation about service delivery.

The training available to staff was impressive, with good access to clinical supervision and opportunities for professional development.

Clinical records captured the care provided and were subject to audit. We found equity of access to services for all prisoners. Infection prevention audits had been undertaken and clinical rooms were generally suitable and clean.

The management of health complaints had improved. We saw evidence of effective face-to- face resolution, and the quality of responses to concerns and complaints was generally good. However, complaint forms were not freely available and often had to be requested directly from health services staff, which potentially limited their use and submission.

A strategic approach to health promotion had been developed and bespoke events took place throughout the year. Patients who arrived at the establishment needing smoking cessation support were supported effectively.

Some secondary care was available onsite, including ultrasound scans and telemedicine. Out-of-hours support was delivered through the NHS 111 telephone line.

A complex case meeting took place fortnightly and was attended by a range of health care professionals. Patients’ care needs were discussed, and planned interventions were monitored and reviewed during the meeting. The management of long-term conditions was good and patient care was appropriately reviewed. Care plans were detailed and informed ongoing care provision.

Urgent mental health support was good. A duty worker was available seven days a week for prisoners experiencing acute distress, and they operated an initial gate-keeping assessment, which was impressive. This support included input into the segregation unit, and the team routinely contributed to all initial ACCT processes and subsequent case reviews, where appropriate.

All routine MH referrals were generally seen and assessed within a week.

Most custody staff had undertaken mental health awareness training, which was a positive development, particularly given the importance attached to the new key worker role.

The integrated substance misuse team provided well-led and coordinated clinical management, seven days a week. Currently, 115 patients were receiving opiate substitute treatment, compared with 66 at the time of the previous inspection, but prescribing input had not increased with this rising demand. The team appropriately prioritised 13-week reviews, and met weekly to discuss the care of the large number of patients with complex needs. A dual diagnosis nurse, who was part of the primary mental health team, provided support to patients with substance- as well as mental health-related problems.

There was a comprehensive in-possession (IP) policy, but inspectors found that not all IP risk assessments were reviewed in line with it. The use of IP medication had increased from 30% at the time of the previous last inspection to 65% in January 2019, which was positive. About a third of the population (330 patients) was prescribed supervised or controlled medication, which included a number of tradable medicines. Officers were now consistently available to supervise the process, which had improved safety and reduced the likelihood of diversion.

The CQC issued 1 Requirement Notice against Regulation Standards.

Recommendations: Health, Well-Being and Social Care:

  • Automated electronic defibrillators should be easily accessible to prison staff, particularly when nurses are not on site.
  • Patient information should be readily accessible in a range of formats and languages.
  • Prisoners with identified mental health needs should be able to access a full range of individual and group psychological interventions.
  • Patients requiring a transfer under the Mental Health Act should be transferred within the current transfer time guidelines.
  • The range of psychosocial interventions should meet identified need and include the provision of medium- to high-intensity courses.
  • Clinical substance misuse services should offer sufficient prescribing input to meet increased demand and complexity of need.
  • Patient medication should be supplied in a timely fashion, to ensure that treatment is not interrupted.
  • In-possession risk assessments should be reviewed in line with the local policy, to ensure that all risks are appropriately managed.

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

  • None identified/reported.

CQC Requirement Notices Issued:

  • Regulation 12: Safe care and treatment. This was in relation to medicines being not always managed properly and safely.

Links/Resources:

News Release – HMP/YOI Moorland
Full Report – HMP/YOI Moorland

HMIP Report: HMP Stocken, Jan-Feb 2019 – Health Summary

This report was on the announced inspection of HMP Stocken (22 January 2019 – 8 February), and was published 29 May 2019.

Points To Note.

The use of illicit drugs, particularly new psychoactive substances (NPS), remained a serious problem. In the survey, nearly half of prisoners said that it was easy to get drugs at the prison. The mandatory drug testing (MDT) positive rate was high, at around 26% over the previous six months, and almost exclusively for NPS.

There had been two self-inflicted deaths since the previous inspection (in July 2015). Prisons and Probation Ombudsman (PPO) recommendations were not always implemented or embedded. Levels of self-harm had increased substantially since the previous inspection and were now comparable with those at similar prisons. Over half of the 184 incidents in the previous six months had concerned just eight prisoners, which is a telling statistic.

For the same six month period, there were a total of 115 Assessment, Care in Custody and Teamwork (ACCT) case management documents had been opened, which represented an increase since the previous inspection. This was noted as being below the number HMIP inspectors usually find at similar prisons.

Several aspects of health provision had deteriorated since the previous inspection and, overall, the service required improvement. There was a lack of robust governance for several areas of health care. The management of medicines had deteriorated, in terms of poor oversight of medicines management, poor stock control and unsafe storage that needed immediate attention. Some patients requiring nursing care did not always receive the treatment they needed, which left patients at risk of their health deteriorating. Care plans were not always followed or regularly reviewed, and primary care staff did not receive regular managerial or clinical supervision. Waiting times for most primary care services were acceptable, apart from long waits to see the physiotherapist and for a routine GP appointment.

Long-term health conditions were managed effectively. However, a lack of oversight of some patients with complex nursing care needs led to poor outcomes. A social care pathway was in place but the recording of planned care was poor. Staff shortages had had an impact on the delivery of some mental health services, including delays in routine assessments, but urgent referrals were seen promptly.

The drug recovery unit provided a positive environment, with a wide range of psychosocial support available. Not all patients on opiate substitution therapy received regular and timely clinical reviews.

Healthy Prison Outcomes:

  • Safety = 3 (2)*
  • Respect = 3 (3)*
  • Purposeful Activity = 2 (4)*
  • Rehabilitation and Release Planning = 2 (3)*

Note: *Previous inspection outcomes in brackets (from July 2015)

Summary: Health, Well-Being and Social Care:

No patient consultation forums had been established and there was no embedded system to gather patient feedback for primary care services.

Mandatory training was well managed, with some opportunities for professional development. Managerial and clinical supervision was in place for mental health and psychosocial staff but there were gaps in primary care managerial supervision, and clinical supervision was not offered.

The health centre was clean and treatment rooms generally met clinical requirements, including regularly checked and calibrated equipment. However, some of the wing-based medication administration rooms did not meet Infection Prevention and Control (IPC) standards. Daily cleaning checks for clinical rooms were not consistently completed. An IPC audit completed in September 2018 had identified some deficits.

Smoking cessation support was available for those who wished to stop nicotine vaping. Two peer health orderlies had been involved in this with health services staff, but these posts had recently become vacant.

Health care applications were triaged by non-clinical staff, so inspectors could not be sure that patients needing an urgent appointment would be identified, posing a potential clinical risk. Waiting times were adequate for most primary care services, but too long for physiotherapy, dental and routine GP appointments. There were urgent appointment slots available in each GP clinic.

There was an effective system to manage the booking of external hospital appointments. There were sufficient prison officer escorts, which meant that few hospital appointments were cancelled for operational reasons.

Health care release and transfer planning arrangements were effective, when health services staff were given sufficient notice. However, there had been occasions when the transfer of a patient’s care had been arranged only after the patient had left the prison, and when prisoners on release had received only a limited supply of medicines.

45% of prisoners reported to inspectors that they had mental health problems, and 58% of these said that they had been helped with these at the prison. During the inspection, the MH team had 60 patients on their caseload, including six with severe and enduring mental health needs.

The MH team received approximately 50 referrals per month from reception, self-referral, and health services and custody staff.

The waiting time for a routine Mental Health assessment was six weeks, which was too long. The manager triaged referrals each morning, prioritising them on clinical need. The team responded to urgent referrals promptly. There was an effective weekly team meeting and good interaction with prison staff.

There was only one psychiatry session per week, which meant that some patients waited too long for a routine appointment and medication reviews.

23% of prisoners reported an alcohol problem, and 33% a drug problem, on arrival; of these, 61% and 63%, respectively, advised inspectors that they had been helped with this while at the prison.

The Inclusion team, although stretched because of staff absence, was actively engaged with 279 prisoners (33% of the population). Eighty-one prisoners (10% of the population) were prescribed methadone, which was the only opiate substitution therapy available at the time of the inspection and limited patient treatment options. A third were on reducing doses. The prison did not receive any prisoners on buprenorphine (a heroin substitute), which needed to be reviewed.

The CQC issued 3 Requirement Notices against Regulation Standards.

Recommendations: Health, Well-Being and Social Care:

  • Effective and robust (clinical) governance structures should be in place, to ensure that all aspects of health delivery meet the needs of prisoners and are safe, including effective oversight of patient care and the immediate implementation of robust and secure medicines management arrangements.
  • Local partnership board meetings should occur more frequently, to provide strategic oversight and effective governance of the service.
  • Screening, immunisation and vaccinations should be offered and implemented in a timely fashion.
  • Specialist sexual health services should be available within the prison, to ensure privacy and dignity.
  • There should be clinical oversight of the appointment system, to ensure that patients are appropriately booked into clinics.
  • Waiting times for some primary care services, including physiotherapy, the GP and dental services, should not exceed clinically acceptable waiting times in the community.
  • Prisoners should have timely access to mental health services, including routine mental health assessments.
  • Prisoners needing treatment for their condition in hospital under the Mental Health Act should be transferred within the timescales established by the Department of Health.
  • Wider options for clinical treatment should be available, in line with national clinical guidance.
  • Joint clinical and psychosocial reviews should be timely, to support effective management and care of prisoners on opiate substitution therapy.
  • Medicines should be prescribed and administered at clinically appropriate times, to ensure optimal treatment.
  • Medication administration should be supervised effectively by prison staff, to ensure confidentiality and compliance, and reduce the risk of bullying and diversion.
  • The medicines management quorate should ensure that medicines storage and oversight are in line with legal and professional standards, and deficits should be immediately resolved.

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

None identified.

CQC Requirement Notices Issued:

  • Regulation 9 – Person-centred care
  • Regulation 12 – Safe care & treatment
  • Regulation 17 – Good governance

Links/Resources:

Press Release

Full Report

HMIP Inspection Report Health Summary – HMP Lewes, Jan 2019

Date of publication: 14 May 2019
Report type: Prison and YOI inspections
Location: Lewes

Background and Context.

HMP Lewes is a medium sized Cat B male Local/resettlement prison. The last inspection was in January 2016. Since then there have been 5 self inflicted deaths and reported incidents of self harm have increased 300%.
On the positive side, 78% of prisoners told the HMIP Inspectors that staff treated them with respect. This finding in itself attracted the notable remark of this statistic being an “unusually high figure for this type of prison.”
A recognition surely of the challenges faced within the local/resettlement prisons across the estate?

Healthy Prison Outcomes:

  • Safety = 2 (2)*
  • Respect = 2 (3)*
  • Purposeful Activity = 1 (2)*
  • Rehabilitation & Release Planning = 2 (3)*
Note: *(Previous inspection outcomes in brackets)

Summary – Health, well-being and social care:

Many prisoners were very negative about the health services, with two-thirds of prisoners in the survey responding that the overall quality was quite or very bad. Services had deteriorated since the previous inspection, most notably mental health services and the provision of nurse-led primary care.

Over half of prisoners said they had mental health problems. Waiting lists were lengthy and the under-resourced integrated mental health team could not meet the level of need.

The range of primary care services was limited and the oversight of prisoners with long-term conditions was poor. The application process for health appointments was very poorly managed. Inspectors found 143 outstanding applications, presenting significant risks to prisoner care.

Managers did not have accurate data on waiting times.

The inpatient unit continued to provide good quality care for some of the most seriously ill patients. However, it still lacked a therapeutic regime and some of the cells were in poor condition. There were five prisoners receiving funded social care packages, and they received good quality care.

In relation to Substance Misuse services, The Forward Trust provided good clinical and psychosocial services for prisoners requiring substance use treatment.
Prison officers did not always manage medication queues effectively, which continued to compromise confidentiality and increased the opportunity for medication diversion.

Dental care was good but some aspects of governance needed immediate attention, particularly the maintenance of fixed equipment.

The CQC issued 3 Requirement Notices against Regulation Standards.

Recommendations – Health, well-being and social care:

  • Health governance structures should be robust enough to identify and effectively address key risks and concerns, and should ensure that prisoners have prompt access to all health services.
  • All health care staff should receive regular clinical and managerial supervision, and be up to date with mandatory training.
  • All health care should be delivered in a clinically appropriate setting that meets infection control standards.
  • There should be a prison-wide strategy and approach to support health promotion and well-being activities.
  • Waiting times for patients should be regularly monitored to ensure prompt access to care.
  • Applications for health care appointments should be reviewed and actioned without delay.
  • The reasons for prisoner non-attendance at health care appointments should always be recorded and reviewed.
  • Prisoners with long-term health conditions should receive regular reviews by trained staff, informed by an evidence-based care plan.
  • External hospital appointments should not be cancelled. (Repeated recommendation)
  • The prison should work with key stakeholders to produce an updated memorandum of understanding and information-sharing agreement for social care provision.
  • Prisoners referred to the service should be reviewed and assessed promptly, and offered a suitable range of mental health interventions within agreed timescales.
  • There should be a regular substance use strategic meeting to support the implementation and development of the strategy.
  • In-possession medication should be prescribed, reviewed and administered by health care professionals adhering to an up-to-date policy and risk assessment that reflects the range of medications prescribed, up-to-date prescribing guidelines, robust risk assessment of patient and medication, and appropriate storage of such medicines/doses. (Repeated recommendation)
  • Custody officers should manage queues during medication collection times to maintain confidentiality and minimise potential bullying and diversion of supplies (Repeated recommendation)
  • Prisoners should have access to routine dental appointments within six weeks.
  • All dental equipment, including the x-ray machine, should be regularly serviced and certified.
  • The provider should maintain an up-to-date file to document local arrangements for radiation protection.

Good Practice – Health, well-being and social care:

None Identified.

CQC Requirement Notices Issued:

  • Regulation 9 – Person-centred care
  • Regulation 17 – Good governance
  • Regulation 18 – Staffing

Links/Resources:

Press Release

Full Report