HMIPS Standard 9
Health and Wellbeing
The prison takes all reasonable steps to ensure the health and wellbeing of all prisoners.
All prisoners receive care and treatment which takes account of all relevant NHS standards, guidelines and evidence-based treatments. Healthcare professionals play an effective role in preventing harm associated with prison life and in promoting the health and wellbeing of all prisoners.
Overall rating: Poor performance
Within HMP YOI Grampian, it was noted that many of the challenges experienced by Aberdeenshire Health and Social Care Partnership (AHSCP) were a reflection of national themes experienced within many prisons across Scotland, such as not having electronic prescribing, difficulties with recruitment and a lack of a national formulary.
It was encouraging to see that since our last visit in June 2018, the Partnership had continued to progress with the Grampian Health & Wellbeing Programme Board, which was established to manage proposed improvements to services and facilitate change. The Programme Board had responsibility for project managing three agreed work streams to improve patient care:
- Substance use
- Mental health, and
- Healthcare service delivery.
During the inspection, inspectors saw examples where substance use and mental health delivery programmes had produced visible improvements and positive service developments. However, inspectors were concerned to see that the Healthcare service delivery project had not progressed in the same way. This was reflective in the areas of concerns raised within the report, such as the development of primary care and pharmacy services within the prison.
The staff spoken with were committed to delivering high quality healthcare and driving improvement. Inspectors also found a number of examples of good practice during the inspection.
Inspectors noted that the ongoing challenge of recruiting and retaining staff were not on the operational or the board risk register. While inspectors are aware that this was a challenge for NHS Grampian in general, the risks associated of not having a full complement of staff to effectively deliver services within the prison environment must be included on both risk registers. There were concerns that the continued reliance on bank/agency staff could result in a dilution of the skill-mix of permanent staff. Business continuity plans should be drawn up for times when staffing levels are either at the minimum or fall below the minimum.
Individuals who arrived at the prison during the day were formally assessed using a standardised health screening tool, to assess their immediate health needs and their risk of self-harm or suicide. However, it was worrying to find that it was not uncommon for individuals who arrived from the islands at night to not be assessed until the following morning. This does not comply with the SPS TTM strategy and was escalated during the inspection.
Information on how to access services, including the confidential self-referral system was given to prisoners on arrival and during their stay in prison. Appointment waiting times were within recommended guidelines but were not routinely displayed for prisoners. Patients’ attendance and access to healthcare appointments and interventions continued to be an issue, even though prisoners were asked to complete a form explaining their non-attendance. A new appointment card system was due to be introduced.
Prisoners could access Healthpoint, a one-stop health information point located within the prison library, but due to limited staffing, access was not always possible. A range of clinics were held in the health centre many of which relied on the availability of trained staff, such as BBV testing.
Prisoners identified as requiring support with their mental health had access to a wide range of treatments and interventions. Those referred to the clinical psychology service and psychiatrist were seen promptly, and all prisoners, including those with complex care needs, were seen to be involved in decisions about their immediate and ongoing care. However, variation in the way staff approached the triage process meant that the basis for decisions was not consistent and almost all referrals were directed to the mental health team, even though it was not at its full complement.
On arrival, prisoners risk of self-harm or suicide was assessed and those identified as being at risk were placed onto TTM accordingly. However, as previously mentioned prisoners admitted to the prison at night were not assessed by a healthcare professional in line with the SPS TTM strategy. Inspectors raised this as a significant concern to the Partnership and the SPS.
The mental health team had a well-established working relationship with community mental health services. Arrangements were in place to notify community services in advance that a patient was expected to return into the community so that the appropriate support could be put in place in time for their release.
Anyone requiring support with substance misuse was identified at their initial health screening on arrival to the prison. Those already on ORT or who requested ORT were assessed and commenced treatment in a timely manner.
The substance misuse team took a whole person approach and held weekly multi-disciplinary meetings to discuss patients care and progress. Individuals referred to the team received a comprehensive assessment of their needs and had access to a range of psychological interventions, such as cognitive behavioural skills for relapse prevention and to maintain their recovery.
Staff were trained in, and had access to training, in a wide range of psychological interventions such as NES core behavioural training and motivational interviewing. Plans were also in place to introduce monthly coaching in a range of psychological skills to support ongoing delivery of psychology care.
As with the mental health team, the substance misuse team had developed strong relationship with a wide range of external and third sector agencies, including CREW (harm reduction and outreach charity) and the alcohol and drugs agency who provided 1-1 sessions, group work and programmes to support prisoners prior to liberation. A standardised discharge tool was used to notify the receiving community services of an individual’s release and to make sure individuals were linked into appropriate support services on liberation.
There was little evidence of collaborative working between the mental health and the addictions team to identify the appropriate support and treatment for individuals. This was an area that both teams expressed plans to address.
Not all individuals with a long-term physical health condition were identified on arrival at the prison, and those that had been were not always followed up in line with current best practice, or, had appropriate care plans and accurate and detailed assessment documentation. This was brought to the attention of the Partnership and progress will be monitored.
Similarly, staff were not informing individuals of their test results, documenting the results or following these up with medical staff when they were outside of normal parameters. This was escalated to the health centre manager for action.
Medical and Pharmacy Service
Despite not having a dedicated pharmacy team, the prison pharmacy service had developed a strong working relationship with the Lloyd’s pharmacist and staff. However, the way the pharmacy service was being delivered within the prison gave rise to significant concerns around patient safety.
Multi-disciplinary medical/pharmacy management meetings did not take place; staff responsible for ordering and managing the day-to-day pharmacy services did not possess specific pharmacy experience; limited kardex monitoring and medicine optimisation took place, and routine and spot checks of in-possession medication were not carried out.
The pharmacy did not hold a current Home Office CD licence and medication was administered to fit in with the prison regime rather than at clinically appropriate times. Both of these issues were escalated as significant concerns.
The prison had established good links with NHS Grampian maternity services, and the women attended appointments at the maternity hospital in addition to seeing the midwife inside the prison. Each women was allocated a named prison social worker and a community based social worker who worked together to support the women maintain contact with their baby or young child during their stay in prison.
The women were located in the dedicated mother and baby cell, had access to a wide a range of equipment, and were offered a comprehensive package of care. A dedicated mother and baby officer was available to ensure the support and advice offered to the women reflected their individual needs.
Culture and Leadership
Complaints, comments and feedback forms were readily available to prisoners within the halls. Overall responsibility for managing and responding to complaints, as well as leading any investigations, sat with the health centre manager, who had introduced a named nurse model which had led to improved response times; early resolution of complaints and a reduction in number of complaints.
The recruitment and retention of staff continued to be a challenge for the healthcare team and is an issue that mirrors NHS Grampian as a whole. Many posts lay vacant necessitating the ongoing use of bank/agency staff, and there was concern that the healthcare team was often operating at below acceptable staff levels to delivery safe care. A general lack of leadership among the nursing team was identified, with less senior staff expected to make clinical decisions without support from senior colleagues. This should be addressed once the team leads and clinical nurse manager have completed leadership and management training.
Staff competencies were not regularly assessed and clinical supervision was not offered to all nursing staff groups. Line management had recently been re-introduced and the health centre manager and the clinical nurse manager held weekly capacity and workforce meetings with the nursing team.