Health Notes from IMB Reports – August 2019 (Pt.2)

The IMB reports published during the latter part of August 2019 were from these establishments:

  • HMP/YOI Rochester
  • HMP Frankland
  • HMP Moorland
  • HMP North Sea Camp
  • HMP Pentonville
  • Dungavel House IRC
  • HMP/YOI Portland
  • Morton Hall IRC

IMB evidence comes from observations made on rota visits, scrutiny of records and data, attendance at various meetings, informal contact with staff and prisoners, prisoners’ applications and monitoring of areas of concern.

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

IMB Report – HMP Rochester

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • Staff shortages noted within the healthcare team, but remains a team of dedicated nurses at the prison, often working additional hours and exceeding what is expected of them.
  • Strained relations between the healthcare provider and the prison, although recent improvements were noted. Prison officers are now in attendance at all clinic sessions, but there are still occasions when wing officers fail to deliver appointment slips to prisoners until it is too late to attend.
  • There is the ongoing of medication being concealing by prisoners, presumably for trading. When identified, such prisoners are referred to the GP for review; as too are those who fail to collect medication regularly or are found to be non-compliant as a result of wing-based medication checks.
  • Delays in outpatient appointments remain, due to a lack of officers being available for escort duty, although it is noted to have improved during the year. As the availability of NPS remains significant in the prison, its effects are the cause of a significant proportion of the emergency A & E call-outs.
  • There were 176 complaints to Healthcare – primarily about medication and external hospital appointments, which is the same position as last year. Complaints to the IMB usually relate to perceived delays in appointments to see GPs or a hospital visit and are generally resolved.
  • An Optician visits the prison every fortnight, and there is a long waiting list. The growing profile of elderly prisoners with deteriorating eye sight adding to this pressure.
  • At time of writing this report, the IMB noted that substance misuse services are supporting 179 prisoners in structured treatment, a further 40 are given unstructured treatment, and 85 are on Opiate Substitution Therapy (OST).
  • Mental health services have a caseload of 77 patients with a 43 referrals in process. The IMB is noting that with the focus on opening up about mental health issues, the team at Rochester are spending more time and energy is helping with prisoners with their mental health issues.
  • Healthcare applications to the IMB increased to 42 from 40 when compared to the previous reporting year.

Full IMB Report – HMP/YOI Rochester


IMB Report – HMP Frankland

Reporting period – 01 Dec 2017 to 30 Nov 2018.

  • Reported self-harming incidents rose to 560 carried out by 83 prisoners compared with 403 carried out in the previous year. At the time of writing HMP Frankland has adopted a new SASH (Suicide and Self-Harm) policy which aims to reduce incidents of self-harm and deaths in custody.
  • The Governor is introducing a specialist into the Segregation Unit to monitor Mental Health issues and has deployed a Nurse Station in the Unit full time.
  • Recruitment of nursing staff continue to cause issues which reflects the national problem.
  • The focus of clinical and professional improvement noted by the CQC was the unmonitored fridge temperatures where drugs are stored, clinical supervision and staff training. Training is now evidenced and continually updated through a combination of face-to-face courses and on-line updates.
  • Although the Healthcare team have been through a particularly difficult year, the staff have engaged well and a tracking system of audits shows discernable improvement indicating a well-led service.
  • There continues to be considerable challenges in Healthcare, in caring for patients who have mental health conditions or non-medical issues who are lodged in Healthcare (in-patients) and could be returned to the wings were they not considered to be too disruptive.
  • An emerging dimension of healthcare for the long term high secure estate (LTHSE) is dealing with long term conditions such as dementia and a range of chronic diseases. Future development of services requires easy access to secondary care expertise to support both patients and staff. This certainly will need innovation and resource to meet this growing challenge. Training for prison staff needs consideration as part of this service development.
  • Overall, waiting times have improved across the range of services offered. Part of the solution is to challenge prisoners to use the telephone lines to cancel appointments and reduce ‘did not attend’, so appointment lists can be managed effectively. If prisoners use the telephone lines correctly, they can seek advice on healthcare issues without necessarily needing a GP appointment. There appears to be a confidence in prisoners using this service and improvements continue.
  • The Patient Consultative Committee (PCC) for Healthcare has been regenerated by the Clinical Lead and has become a focussed meeting actively seeking prisoner engagement. Following the CQC visit, the prisoners have been asked to contribute to the service review so healthcare services are ‘fit for purpose’. After initial hesitancy and some negativity, the meeting is going from strength to strength with a far more ‘can do’ attitude and honest dialogue.
  • A long term problem within Healthcare is the unacceptable waiting times prisoners experience when attending out-patient appointments. At the time of writing the report, the Governor has approved two posts who are effectively ‘Move Officers’ who can move prisoners back to their wings in order to tackle this problem. Priority transfer will be given to prisoners who are going to education or work so they do not miss out on morning or afternoon activity.
  • Healthcare applications to the IMB remained unchanged with 15 when compared to the previous reporting year.

Full IMB Report – HMP Frankland


IMB Report – HMP Moorland

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • HMP Moorland has benefited financially this year by being nominated as one of the prisons in the 10 prison project (10PP). The focus of this programme is on improving decency, leadership and the reduction of violence and drug-use within the prison.
  • Notable statistics for this reporting year include: 578 ACCT documents opened, 755 incidents of self-harm, 45 constant supervisions, 198 prisoner-on-prisoner assaults and 119 assaults on staff.
  • Mental health staffing has been increased so that care is now available 7 days per week, and prisoners put on an ACCT can be seen within 24 hours.
  • The overall cancellation rate for hospital escorts reduced to 8.1%, which equated to 62 cancellations from the 769 that were planned.
  • The number of psychoactive substance (PS) incidents have significantly decreased over the year, most likely as a result of the 10PP investment and additional resources. This reduction means that the 1–1 interventions with the Substance Misuse team are now more effective.
  • Overall the IMB is satisfied that healthcare services including mental health, substance misuse, and the arrangements for social care are of a standard equivalent to those available to the general population.
  • Healthcare applications to the IMB increased to 52 from 29 when compared to the previous reporting year.

Full IMB Report – HMP Moorland


IMB Report – HMP North Sea Camp

Reporting period – 01 Mar 2018 to 28 Feb 2019.

  • HMP North Sea Camp has adopted a rehabilitative culture and now refers to the prisoners as residents.
  • The Board is satisfied that healthcare provision at the prison is generally of the equivalent standard to that provided outside prison and, in some cases, exceeds it.
  • Typical waiting times for residents seeking medical attention are generally seen the same day by a triage nurse, and within a modern healthcare facility. GP appointments are facilitated within about a week. Optometry waiting time is within 4 weeks. Residents requiring urgent access to mental health services are seen within the same day. Residents are referred for screening programmes such as abdominal aortic aneurysm (AAA) screening and diabetic retinopathy screening within the same timescales as in the community.
  • The Board is pleased to note that the health provider continues to provide the finance to employ 4 extra prison officers to escort residents to hospitals and for bed watches when required. This has made a considerable difference to residents’ treatment in that appointments rarely have to be cancelled and rearranged. Escort duties no longer negatively impact on the prison regime which was the case in the past.
  • There are plans for the extension of the Healthcare centre during the 2019/20 financial year with funding from NHS England.
  • At periods throughout the year, and particularly for the compilation of this report, Board members have sought the opinions of the residents as to the standard of healthcare they receive. Whilst there are on occasion some complaints, and 12 healthcare-related applications to the IMB, in the main their opinion is favourable. One resident said recently of his treatment, leading to a surgical operation, that he was “impressed and delighted” with the service he had received, particularly by the staff at the Healthcare centre.
  • The percentage of residents over 50 years of age has increased and continues to do so. The health needs of an older population are well documented. Long term chronic age related issues include COPD, diabetes, cancers, mobility problems, arthritis, anxiety and increased comorbidity (2 or more long-term conditions). There is also an increase in those registered as “disabled”.The Board considers that the prison currently meets the healthcare needs of the population. However, going forward, it is likely that there will need to be more healthcare staff to service the increasing healthcare needs of an ageing prison population.
  • A small but very efficient unit of two mental health nurses provides an excellent service. There is an open-door policy and “nobody is ever turned away” from seeking help at the door. The team are part of the Quality Network for Prison Mental Health Services (QNPMHS) – the national peer review quality network. At the annual reviews for the last two years they were rated as the best MH team in the country, when rated against other participating prisons.
  • However, this small team have a heavy personal caseload and a lack of support. Between the two of them they currently have a combined personal caseload of over 50 patients. During the year to end of February 2019, the team dealt with a combined caseload of 224 patients. In addition, they run mental health awareness days, and give ongoing support to other patients in conducting “wellbeing interviews” There is currently no patient waiting list to see a mental health professional.
  • At the time of reporting, 22% of the residents at this prison are classed as “disabled” in some way and 30 residents have a personal emergency evacuation plan (PEEP) in place to assist them to leave their rooms safely in the event of an emergency. The prison has recently formed a team of five “residential support workers” – residents who are employed to support 20 disabled residents who are on PEEP plans.
  • In previous reports, the IMB have raised concerns about certain aspects of healthcare. The provision of dentistry has been addressed by the introduction of a mobile dental van (since Nov 2018). Residents get to see a dentist quite quickly now (within 4 weeks typically) for an initial assessment; however, there is typically a 10 week wait for treatment unless the resident is in severe pain or has a deep infection. Credit is given to the clinical lead at HMP North Sea Camp who has fought hard to get this service provided.
  • Healthcare applications to the IMB decreased to 12 from 15 when compared to the previous reporting year.

Full IMB Report – HMP North Sea Camp


IMB Report – HMP Pentonville

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • One recorded self-inflicted death this year compared with 3 and 6 deaths respectively for the last two years, bucking the national trend.
  • ACCT numbers have risen from 709 to 742 reflecting a trend seen across the prison estate since the introduction of Key Workers – a scheme carving out regular dedicated time for officers to support prisoners and pick up on issues – and the influx of newly trained officers. Many ACCTs are able to be closed within a day once immediate concerns are addressed.
  • Reported incidents of self-harm have increased this year to 598 from 500 in the previous year.
  • Mental health staff cannot always attend initial ACCT case reviews. Although a nurse is allocated Monday – Friday for this duty, the reviews are not well coordinated by the prison.
  • All health referrals are considered at a daily meeting of the Wellbeing team (Primary Care, In Reach Mental Health, the Wellbeing Centre, and Building Futures). This ensures co-ordination of provision and prevents time wastage by misdirected referrals.
  • The outstanding Wellbeing Centre has strong leadership and a motivated team. Largely refurbished, the services now include activities such as cooking and baking. Users are very enthusiastic about the activities and the staff.
  • National policy to return prisoners from secure psychiatric units to the nearest prison means that Pentonville receives a disproportionate number of such prisoners, putting pressure on the prison’s mental health services.
  • Wellbeing Centre staff continue to report that ACCT documents are not always sent across with prisoners.
  • No dedicated rooms on the wings for mental health staff to use for assessments means interviews take place in difficult conditions with little privacy.
  • A substance misuse through-the-gate worker may accompany an offender to key appointments on release and keeps in touch for up to three months.
  • Last year, the Board said it should be a prison priority to ensure that misusers go to the designated wing where extra medical support is available. The risk to life of alcoholics in first days of detox is acute. However, some men are still scattered across the prison endangering life.
  • Healthcare applications to the IMB decreased to 73 from 114 when compared to the previous reporting year.

Full IMB Report – HMP Pentonville


IMB Report – Dungavel House IRC

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The numbers detained at Dungavel dropped significantly during the reporting year. This was in line with other establishments throughout the Immigration Estate.
  • The capacity of the Centre is 249. This is made up of 235 male beds, 14 female including the 3 disabled beds.
  • There were 21 detainee-on-detainee assaults, and 3 detainee-on-staff assaults and during the reporting period.
  • There is no medical recording IT system in the Health Centre. This results in an increased amount of clinical time being spent dealing with paper files. The Scottish Prison Service do not always pass on medical notes for Time Served Foreign National Offenders (TSFNOs).
  • Detainees are seen by a nurse within two hours of admission and offered an appointment with a doctor within 24 hrs. The health centre has open access but all further requests for an appointment are triaged by a nurse and detainees can then see a doctor within 24 hours. Medication is dispensed three times a day with an officer in attendance.
  • The mental health team help with anxiety, relaxation and anger management where detainees are having difficulty coping with situations in detention. They also run a horticultural group.

Full IMB Report – Dungavel House IRC


IMB Report – HMP/YOI Portland

Reporting period – 01 Apr 2018 to 31 Mar 2019.

  • The Board’s concerns regarding healthcare provision in general have changed little over a number of years. They involve issues about the way the prison facilitates the delivery of healthcare services as well as aspects of service provision delivered by the health provider. Whilst the senior management team and the healthcare lead are alert to the issues, there has been improved collaboration between the two services, but the IMB view is that access to the services provided in Portland are still not on a par with services in the community.
  • A service user forum has been established for the first time this year.
  • A seemingly intractable problem impacting on the smooth and safe delivery of healthcare services, is the timely, efficient and effective dispensing of medicines. Until recently facilitating the dispensing of medication was not a profiled duty for operational staff on the wings. The result was that, despite the fact that 25% of the population are in receipt of daily medication and between 50–60 prisoners, at any one time, are on a methadone script, no officer was allocated the responsibility of escorting prisoners to and from the dispensary in the healthcare building.
  • Deficiencies in the deployment of operational staff to provide support for the delivery of health and social care services are being addressed, but there is little evidence that the time taken to dispense medicines has improved. The knock-on effect is that subsequent clinics run late, have to be curtailed or are cancelled so prisoners face significant delays in accessing appointments with specialist service providers.
  • The Board continues to have concerns about the profile of the healthcare team. A shortfall in mental health staff and difficulties appointing and retaining staff means that the limited resource has to be focused on mental health assessments. As a consequence, treatment is based on drug therapy rather than psychosocial support as a treatment for mentally disordered prisoners.
  • At the time of writing of the report, there was no psychiatrist in post on the mental health team, although one had been appointed. The nursing complement does not appear to be adequate for the requirements of the prison. It is currently taking 5 weeks to access a mental health appointment. Although this year has seen an improvement, staffing shortages mean that segregation and ACCT reviews take place without a mental health or other health representative, or are attended by a staff member who has minimal knowledge of the prisoner.
  • Mental health data for July and August 2018 evidenced that in the respective months only 190 out of 313 (61%) and 157 out of 252 (62%) were brought for their appointment. Prisoners and wing staff are alerted to appointments by healthcare the day before via an appointment slip. In December a wodge of these undelivered appointment slips was found in waste management.
  • More recently changes to the funding of substance misuse services from the Prison Service to NHS public health teams have seen some downgrading of its priority. This will have a significant impact on the service, which holds an average caseload of 200 prisoners at any one time.
  • Healthcare applications to the IMB increased to 27 from 23 when compared to the previous reporting year.

Full IMB Report – HMP/YOI Portland


IMB Report – Morton Hall IRC

Reporting period – 01 Jan 2018 to 31 Dec 2018.

  • The operational capacity of Morton Hall is 391 detainees. For much of 2017 the centre operated nearly at full capacity. However, in keeping with other IRCs, the roll fell significantly during 2018; the average figure for the year was 293.
  • The average length of time detainees spent at Morton Hall during 2018 was between 2 and 4 weeks.
  • Healthcare provision at Morton Hall continues to build on the former HMIP/CQC Inspection reports with respect to strong clinical leadership, an effective team approach, an integrated service, sound governance and a good partnership with the centre’s management team.
  • Mental health provision has continued to improve. There has been an increase in the staff component from 3 to 6, now consisting of 2 clinical matrons, 3 senior mental health nurses and 1 mental health nurse.
  • The contribution of the Substance Misuse Practitioners is applauded by the IMB; their service is well used by detainees who often commend its quality and availability.
  • For the second year running the Mental Health Team has been recognised in the Quality Network for Prison Mental Health Services (QNPMHS) Peer Review (2018) as offering a high- quality service, coming second with a score of 91% of standards fully met. The site that placed first (North Sea Camp) has the same healthcare provider.
  • While healthcare is an agenda item on the monthly Residents’ Representative Group’s meetings, detainees feel they have limited involvement in the governance and development of the service. This is possibly a matter for future consideration.
  • Wellbeing Days are held monthly. They continue to be supported by all pathways; primary care; mental health and substance misuse.
  • The healthcare team continues to be proactive with respect to the management of complex cases. Complex case meetings are held every week and attended by everyone on shift, including primary care, mental health, substance misuse and pharmacy.
  • Healthcare applications to the IMB decreased to 11 from 19 when compared to the previous reporting year.

Full IMB Report – Morton Hall IRC


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