Report on Full Inspection of HMP & YOI Grampian: 4 - 15 February 2019

Annex A: Summary Of Recommendations

For the Governor

Recommendation 1: HMP YOI Grampian reception staff should ensure that the information booklets are in the language indicated on the front cover.

Recommendation 2: HMP YOI Grampian management should ensure that all residential staff are aware of the translation services available to prisoners and how to access them.

Recommendation 3: HMP YOI Grampian management should ensure that a process is in place to evidence primary and secondary assurance of the CSRA process.

Recommendation 4: HMP YOI Grampian management should consider expanding the use of peer mentors to assist with the induction process for adult male prisoners.

Recommendation 5: HMP YOI Grampian management should ensure that all protection prisoners have full access to national induction.

Recommendation 6: The SOP governing the liberation process should be followed at all times, whereby a clear handover takes place between reception and front of house staff within the agents visits area.

Recommendation 7: HMP YOI Grampian should consider moving the air conditioning unit inside or provide more protection in its current location.

Recommendation 8: HMP YOI Grampian should increase their escort cover to a suitable level to allow the estates team to reduce the number of agile requests with a red status.

Recommendation 9: To allow a feeling of self-worth and dignity, HMP YOI Grampian should ensure that prisoners are given every opportunity to keep their cells clean, and cell-cleaning periods should not be missed.

Recommendation 10: HMP YOI Grampian should make every effort to reduce new admissions being allocated to cells where there is graffiti, particularly where it is offensive and inappropriate.

Recommendation 11: In line with job descriptions, HMP YOI Grampian should deliver adequate BICS and biohazard training.  No person should undertake tasks where they have not undergone the appropriate training.

Recommendation 12: HMP YOI Grampian should ensure that cleaning audits take place to ensure that standards of cleanliness are met.

Recommendation 13: All laundry stores should have an appropriate quantity of bedding.

Recommendation 14: The washing machines and tumble dryers in Banff Hall should be utilised.

Recommendation 15: The process for returning laundry to the correct location should be reviewed and refined.

Recommendation 16: HMP YOI Grampian should ensure there is a sufficient amount of toiletries and hygiene products available in all stores to meet the needs of prisoners in that area, and in particular first night in custody prisoners should be given their full entitlement.

Recommendation 17: HMP YOI Grampian should ensure that only those wearing appropriate clothing are permitted within the kitchen area.

Recommendation 18: HMP YOI Grampian should ensure that sufficient quantity and quality of clothing is available to all prisoners throughout the prison.

Recommendation 19: HMP YOI Grampian should take action to improve the fabric and the cleanliness of the safer cells in Ellon Hall, and a window covering should be sourced for the safer cell in Banff Hall.

Recommendation 20: As a matter of urgency, HMP YOI Grampian should review the regimes and location for offence and non-offence protection prisoners in Ellon Hall, and their location.

Recommendation 21: The use of the auxiliary cell in the SRU should be reviewed and action taken to significantly reduce its use, with a view to ceasing it all together.

Recommendation 22: The paperwork used to record the use of the auxiliary cell should be consistent with entries on R2 and HMP YOI Grampian should review their processes around this.

Recommendation 23: HMP YOI Grampian should look to adopt a more proactive approach to addressing challenging behaviour in the SRU, as opposed to repeated use of the auxiliary cell.

Recommendation 24: HMP YOI Grampian should take immediate action to ensure the Think Twice Strategy is fully implemented across the establishment.

Recommendation 25: Immediate action should be taken to ensure consistent and effective support is available to people who are experiencing bullying and harassment.

Recommendation 26: HMP YOI Grampian should take action to address the gaps in health and safety practices and ensure relevant staff are trained to meet the requirements of their posts.

Recommendation 27: HMP YOI Grampian should ensure that all planned control and restraint removals are recorded.

Recommendation 28: HMP YOI Grampian should find another way of keeping SSM forms safe and secure and away from the population to protect prisoner confidentiality.

Escalated Recommendation 29: HMP YOI Grampian should ensure that regular and consistent searching is carried out throughout the establishment, and that it is properly documented and escalated as appropriate.

Recommendation 30: Items in use proformas should record the date of applying for the items and the timescales should be reviewed and trigger points identified if this flags up lengthy delays.

Recommendation 31: HMP YOI Grampian should re-introduce suspicion testing on the male population.

Recommendation 32: HMP YOI Grampian may wish to consider allowing low supervision prisoners to move up and down the route unescorted to free up staff time.

Recommendation 33: HMP YOI Grampian should ensure that all staff are aware of the policies or SOPs and how to implement them in relation to the sharing of information.

Recommendations 34: HMP YOI Grampian must ensure that inappropriate behaviour is consistently challenged and positive behaviours are consistently reinforced to ensure a safe environment.

Recommendation 35: HMP YOI Grampian must take necessary steps to protect protection prisoners from abuse.

Recommendation 36: HMP YOI Grampian must ensure computer screens and personal information cannot be viewed by prisoners.

Recommendation 37: HMP YOI Grampian must ensure prisoners in Ellon Hall have the opportunity to secure their cells when not in them.

Recommendations 38: HMP YOI Grampian should ensure that staff are familiar with all documents including SOP’s relative to their working environment, in particular to managing staff shortages.

Recommendations 39: HMP YOI Grampian should ensure that prisoners are aware of the available regime and have equity of access to it.

Recommendations 40: Prisoners should be consulted about changes to the regime and it should be effectively communicated.

Recommendations 41: As with QI 5.4 improve communications regarding available regime.

Recommendations 42: As with QI 5.4 ensure equity of access in relation to the available regime.

Recommendation 43: Improve access to information for non-English speakers to safeguard themselves against mistreatment.

Recommendation 44: Improve access to the regime so that prisoners are not required to choose between entitlements.

Recommendations 45: HMP YOI Grampian should ensure that staff have the required information to allow them to inform those in their care of the SPSO process.

Recommendations 46: HMP YOI Grampian should ensure that those that have lower levels of literacy are supported to complete the required paperwork, without reliance on other prisoners, unless it is a peer supporter.

Recommendation 47: The education unit should promote their service further using noticeboards and personal contact to ensure greater take up of provision.

Recommendation 48: HMP YOI Grampian should revise their regime plans to ensure that all prisoners are offered access to time in the fresh air.

Recommendation 49: HMP YOI Grampian should ensure all exercise areas are clean and consider how these could be developed to contribute further to positive health and wellbeing.

Recommendation 50: HMP YOI Grampian should remove barriers to access by revising routes to exercise to ensure that these are safe and challenging abuse of any kind promptly and appropriately.

Recommendation 51: HMP YOI Grampian should ensure the specification and implementation of security check procedures for the exercise process are robust.

Recommendation 52: The existing chaplaincy plan should be refreshed taking account of learning on trauma informed practice for both staff and prisoners and how this might be extended across the wider establishment.

Recommendation 53: Arrangements should be made to facilitate attendance at services by those on non-offence protection to promote inclusion.

Recommendation 54: HMP YOI Grampian should ensure relief cover arrangements are in place for the visits booking line on occasions when the administration staff are not available.

Recommendation 55: HMP YOI Grampian should ensure that information about visits is refreshed and accessible; including for prisoners whose first language is not English.

Recommendation 56: HMP YOI Grampian should ensure that any information recorded about families has appropriate consent arrangements in place and is GDPR compliant.

Recommendation 57: HMP YOI Grampian should track those prisoners who are socially isolated and consider implementing alternative forms of support.

Recommendation 58:  HMP YOI Grampian should reintroduce video links for families in the Shetland Islands, and make more use of video link in general to facilitate contact with families.

Recommendation 59: Prisoners and families should not be routinely notified that their closed visit period is for an initial three-month duration.

Recommendation 60: HMP YOI Grampian should ensure consistent contact between prisoners and identified personal officers, who report feeling confident in carrying out their duties to a high standard with access to appropriate support and development opportunities.

Recommendation 61: HMP YOI Grampian should review the availability of life skills and pre-release opportunities to make these accessible to a wider population.

Recommendation 62: HMP YOI Grampian should arrange for appropriate technology equipment to support effective remote working for the TSO group.

Recommendation 63: The SPS should review the use of Cruden Hall as part of the progressive footprint for throughcare.

Recommendation 64: Future planning should be better communicated to partner agencies to support further development.

Recommendation 65: HMP YOI Grampian should ensure that prisoner’s attend appointments in the link centre on time.

Recommendation 66: HMP YOI Grampian should reintroduce advocacy services to assist prisoners to exercise their rights.

Recommendation 67: HMP YOI Grampian should ensure that those staff involved in personal officer roles have the appropriate training and time to carry out the role.

Recommendation 68: There is a need for a more defined personal officer scheme, with protected time, to improve the delivery of the personal officer function.

Recommendation 69: Development of a full Equality and Diversity Action plan must now be prioritised and those tasked with its development given sufficient time and support to complete the exercise speedily.

Recommendation 70: Training in Equality and Diversity impact assessments should be prioritised and a systematic programme of assessments carried out across the prison.

Recommendation 71: A single RAG scoring system should be applied consistently for the monitoring of all action plans.

Recommendation 72: When action points are assessed for closure, more attention should be given to whether the underlying issue raised by the scrutiny body had been fully addressed or whether further action was still required.

Recommendation 73: HMP YOI Grampian should undertake more strategic planning around the type of services needed in future, the role of partner organisations in providing those services and how any funding gaps might be addressed.

For the SPS

Recommendation 74: The SPS should improve the standard of mattresses and pillows to allow prisoners to get a better night’s sleep, and allow them to be more prepared physically and mentally for the next day’s activity.

Recommendation 75: SPS should consider amending the TTM paperwork so that there is a clear and easily accessible record of required checks being completed.

Recommendation 76: SPS should ensure that the interpretation of children’s visits criteria is as inclusive as possible and consistently implemented across establishment sites.

Recommendation 77: SPS should consider introducing phones for each cell to facilitate easier contact between prisoners and families.

Recommendation 78: Scottish Government and the SPS should urgently seek funding routes to maintain and further develop parenting courses for serving prisoners at HMP YOI Grampian.

Recommendation 79: SPS should keep the national processes for psychology resourcing and access to programmes under review, ensuring that the experience of users and staff are recognised and any unintended barriers to participation in addressing offending minimised.

Recommendation 80: The SPS should consider the resourcing of a pilot throughcare process for remand prisoners at HMP YOI Grampian.

Recommendation 81: The SPS should review the national waiting list for programmes as it does not appear to be resolving the progression issues and was disruptive in HMP YOI Grampian.

Recommendation 82: The SPS should take the necessary steps to provide TSOs with the necessary IT to allow them to operate more effectively in the community while mobile working.

Recommendation 83: SPS HQ to work creatively with HMP YOI Grampian to urgently identify and implement solutions to their recruitment challenges, as existing detached duty arrangements are not effective or sustainable in the longer term.

Recommendation 84: SPS HQ and HMP YOI Grampian should jointly explore the potential to make greater use of new technology to improve access to services and support contact with families as well as easing administrative burdens on staff.

Recommendation 85: SPS should consider if some college courses could be delivered locally.

Recommendation 86: SPS and HMP YOI Grampian management should ensure that prisoners are taken to their appointments timeously.

Recommendation 87: HMP YOI Grampian management should ensure that they do everything possible to ensure that prisoners are taken to their appointments timeously.

For the Scottish Government

Recommendation 88: Scottish Government and the SPS should urgently seek funding routes to maintain and further develop parenting courses for serving prisoners at HMP YOI Grampian.

For NHS Grampian

Recommendation 89: The NHS should take action to address the delay in mental health support for people who are subject to TTM.

Recommendation 90: NHS Grampian should consider how mental health services both in the prison and the community could be better linked with case management and release processes.

Recommendation 91: The Partnership and SPS should work together to ensure that there is a robust process in place to ensure that those prisoners arriving late into the prison receive a formal health screening assessment.

Recommendation 92: SPS and HMP YOI Grampian management should ensure that prisoners are taken to their appointments timeously.

Recommendation 93: The Partnership and SPS must work together to ensure that they are accurately collecting data on the number of missed appointments, reasons for them, and the impact it has on the delivery of healthcare.

Recommendation 94: The partnership must ensure that sufficient trained and competent staff are available to undertake core duties in the health centre, including venepuncture and blood-borne virus testing.

Recommendation 95: The Partnership must ensure that health promotion information displayed for prisoners around the prison includes information on how to access condoms, Naloxone training and the risks of taking drugs.

Recommendation 96: The Partnership should develop local protocols covering joint working and information sharing.

Recommendation 97: The Partnership should review the mental health referral process ensuring that there is transparency on how long patients will need to wait for assessments.

Recommendation 98: The Partnership must ensure that patients with long-term physical healthcare needs are reliably identified, the appropriate care packages are put in place which are discussed and agreed with the patient and documented in the their record.

Recommendation 99: The Partnership must ensure that patients who have test results outside accepted parameters are referred to an appropriate member of the healthcare team to ensure any corrective actions are taken.  This information must be recorded in the patient record.

Recommendation 100: The partnership must review how the Pharmacy service in HMP YOI Grampian is delivered to ensure that the service is managed and delivered safely and effectively.

Recommendation 101: The Partnership must ensure that medication is administered as prescribed to minimise the risk of harm to patients. This includes ensuring that doses are not taken too close together or outwith the time of day at which they are prescribed.

Recommendation 102: The Partnership must ensure that all staff involved in the administration of controlled medicines check the patient identity, drug, dose and amount to be administered to minimise any errors.

Recommendation 103: The Partnership must ensure that all care plan documentation for pregnant women focussed on outcomes and incorporates the woman’s personal strengths and wishes.

Recommendation 104: The Partnership must develop policy to manage patients who require palliative or end of life care.

Recommendation 105: The Partnership must ensure that all staff managing complaints receive appropriate training to ensure that complaints are correctly managed.

Recommendation 106: The Partnership must ensure that hand hygiene audits are regularly undertaken by an appropriately trained member of staff, and that actions are taken to address any non-compliances noted.

Recommendation 107: The Partnership must ensure that the development and provision of infection prevention and control guidance and tools are prioritised within the prison to minimise risks to patients and staff.

Recommendation 108: The Partnership must ensure that all staff are competent to undertake their roles, and that there is a regular assessment of staff competencies to maintain patient and staff safety.

Recommendation 109: The Partnership must ensure that clinical supervision is offered to all clinical staff and that these staff are encouraged to take up this supervision. This will ensure that staff are supported in their reflections of actions they have taken, and have the opportunity to discuss their decision-making, especially in more stressful or complicated situations.

Recommendation 110: The Partnership must ensure that training for healthcare managers within HMP YOI Grampian is prioritised. This will ensure healthcare managers are given the skills to effectively manage healthcare services in the prison, promote confidence and resilience in the management team, and provide assurance to the board and staff that healthcare management within the prison is robust.

Recommendation 111: The Partnership must assess and manage the risks associated with the use of a significant number of bank/agency staff whilst maintaining staff and patient safety.

Recommendation 112: The Partnership and SPS must work together to ensure that they are accurately collecting data on the number of missed appointments and the impact of this on delivery of healthcare.

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