Report on Return Visit to HMP & YOI Grampian - 11-13 June 2018

Report on Return Visit to HMP & YOI Grampian, 11 - 13 June 2018

ISBN 978 1 78781 229 1 (Web only publication)
PPDAS 471626

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Contents

Introduction

Return Visit Findings

Annex A: Inspection Team

Annex B: Acronyms

Overview by HM Chief Inspector of Prisons for Scotland

Introduction

This inspection was undertaken and completed by my predecessor David Strang QPM.

However, the report was compiled and published after his tenure ended.

When HM Inspectorate of Prisons for Scotland (HMIPS) undertook a full inspection of HMP & YOI Grampian between 30 November and 11 December 2015, a number of concerns were raised in relation to the provision of Healthcare within the establishment.  These concerns were such that Standard 4, Health & Wellbeing was graded as ‘poor performance’.  It was decided at the time that HMIPS would return to HMP & YOI Grampian at some time in the future, in partnership with colleagues from Healthcare Improvement Scotland (HIS), to formally assess progress.  

This report is based on our findings during the return visit, which was undertaken between 11 and 13 June 2018.  The report focusses solely on the Healthcare services, provided by Aberdeenshire Health and Social Care Partnership (AHSCP), within the establishment.

I would like to thank the inspectors from HIS, who undertook the vast majority of the inspection activity on this occasion.

My Conclusion

What was immediately evident was the effort that had been made by the AHSCP and HMP & YOI Grampian to address the concerns raised in 2015.  

Following the last inspection there had been changes to the hosting arrangements for prisoner healthcare in HMP & YOI Grampian, with AHSCP taking over responsibility in 2016.  This had clearly had a positive impact.  A new partnership manager and location manager had been put in place, and both were experienced in the delivery of services to people with multiple and complex needs at both operational and strategic level. 

It was also evident that a revised and more resilient governance structure had been established, and there was clear collaboration between the AHSCP and HMP & YOI Grampian in identifying potential areas for development and improvement.  The establishment of a jointly chaired programme board is to be applauded, and all indications were that this approach had already proved beneficial.

One of the most striking changes was the positive change in the morale of the healthcare team.  Previously they had felt isolated and demotivated, which was no longer the case.  Staff told inspectors that they enjoyed working in the establishment now, but recognised that staffing levels created some additional challenges.

Whilst the healthcare team had been operating without a dedicated manager for some time, this was in the process of being rectified.  It is absolutely vital that this individual receives the support they require as they settle into their role and start to address the challenges that still exist.

Staffing complements had increased since the 2015 inspection.  However, this level of staffing had never been achieved, and the healthcare team had access to an experienced group of nursing resource from NHS Grampian’s staff bank which is not ideal.  Of particular concern was the enduring shortage of mental health nurses (MHNs), an issue that apparently affects the wider NHS Grampian board area.  Given that the shortage of MHNs has existed for a number of years, and appears to be a wider issue, it may be that the AHSCP and NHS Grampian needs to consider alternative delivery models for mental health services within HMP & YOI Grampian.

It was also of some concern that valuable resources were being wasted as a result of prisoners not turning up for clinics and appointments.  Local HMP & YOI Grampian management should ensure that they do everything possible to ensure that prisoners are taken to their appointments timeously, and where necessary encourage those who are minded not to attend as arranged

The prison now has a recovery action plan in place to improve and develop health services within the prison so that they meet prisoner’s healthcare needs.  The action plan includes the development of new processes and pathways of care, and improved training and support for staff, as well as linking in with existing services across the partnership.  Although there is still considerable work to do, inspectors saw how the action plan had had a positive impact on progress since the last inspection.  

Next Steps

This report identifies a number of areas where significant progress has been made, and other areas where improvements are still outstanding.  However, it was clear that the staff and management of the AHSCP and HMP & YOI Grampian are working to a plan, and that they have the support needed to ensure that the changes already made are sustained, and that any future changes are sustainable.  All parties involved should take credit for the manner in which they have approached the task they were set.

HMIPS will continue to monitor progress through regular monitoring visits undertaken by Independent Prison Monitors and inspectors.

Wendy Sinclair-Gieben
HM Chief Inspector of Prisons for Scotland
26 September 2018

Return Visit Findings – Standard 4 Health and Wellbeing

About this report

In December 2015, HMIPS carried out a full inspection of HMP & YOI Grampian, and Standard 4 ‘Health and Wellbeing’ was graded overall as being ‘poor performance’. 

From 11 to 13 June 2018, HMIPS, supported by inspectors from HIS, revisited HMP & YOI Grampian to assess the progress made since the full inspection.

This report sets out the findings from the return revisit to HMP & YOI Grampian.  It focuses on healthcare provision specifically and is structured as follows:

• governance/leadership
• staffing
• primary care provision
• infection prevention control
• health Improvement
• medication management and; 
• mental health.

How we carried out the return visit

Prior to the return visit the team analysed the full inspection report and the improvement action plan, along with supporting evidence provided by AHSCP.

During the visit the team spoke with members of staff and patients, and reviewed care plans and other documentation such as daily records and incident reports.  A focus group was held to allow staff and prisoners to speak with members of the inspection team. 

Governance/leadership

Aberdeenshire Integrated Joint Board (IJB) maintained strategic oversight and overall governance of the health centre in HMP & YOI Grampian, and considered prisoner healthcare as a priority area.  Structured processes for regular reporting on performance with the other IJBs in Grampian (Moray and Aberdeen City) were in place, which provided opportunities to promote awareness and support improvements in health care for the patient population within the prison.  This is good practice. 

A Grampian Health & Wellbeing Programme Board had been established to manage proposed improvements to services and facilitate change.  The Programme Board also had responsibility for project managing three agreed workstreams to improve patient care: 

• Substance use 
• Mental health, and 
• Healthcare service delivery. 

The Programme Board adopted a collaborative approach to working with key partners, including the Scottish Prison Service (SPS), to develop and deliver an integrated healthcare model of care between HMP & YOI Grampian and the community.  It was encouraging to see that the Programme Board had clear senior leadership.  The joint chairs were the Governor-in-Charge at HMP & YOI Grampian and the Chief Officer of the AHSCP.  Each workstream had a dedicated Chair, terms of reference and multi-disciplinary and multi-agency membership, including operational managers from SPS and the AHSCP.  This is good practice. 

Although inspectors observed the positive impact the workstreams were starting to have on patient care, we would encourage the partnership to adopt a more focused ‘SMART’ objective approach to their workstreams.  This would allow AHSCP to focus on and prioritise shared objectives.  We were pleased to see that each workstream took a person-centred approach, placing patients at the forefront of health and care delivery.  That said we would encourage AHSCP to improve its consultation and communication processes with patients on the work of the Board, and to use patient feedback in more constructive and meaningful ways to inform on-going development work. 

Healthcare staff within the prison told us that they no longer felt they were ‘alone and isolated’ and valued the continued input and support from AHSCP.  We heard that morale within the healthcare team had improved and that there had been a cultural shift in how the teams supported each other and in the way they communicated.  External facilitators had provided sessions to staff to work on key areas of development such as ‘positive behaviours’ and how to have ‘courageous conversations’.  The staff we spoke to during the return visit told us that despite the ongoing challenges they enjoyed working in the team.

Staffing 

During the 2015 inspection the healthcare team had found it challenging to maintain a consistent workforce to deliver services.  Staff sickness, challenges in recruiting to key posts, and retaining staff had all impacted on the range of interventions and treatments offered to patients. 

During the return visit, senior managers told us that nurse staffing levels continued to be an issue in HMP & YOI Grampian.  Inspectors were told that the original nursing complement agreed when the prison opened, had been insufficient given the layout of the prison and the range of healthcare needs within the patient population.  As a result an additional resource of 4.78 WTE had been agreed, but due to a high turnover of nursing staff this had not yet been realised. 

Inspectors were told that nurse staffing levels had reached a critical low in the health centre during July and August 2017.  In response managers had taken immediate action and identified a number of priority actions, listed below, and staffing levels had now improved. 

• A nursing risk assessment and action plan. 
• Revision of the approach to nurse recruitment, including options for part-time hours and flexible working where possible, and for potential new staff, the offer of a shadow-shift prior to confirming an appointment so that they were aware of the prison environment prior to commencing work.
• Collaborative working with SPS management to maintain a safe service with a focus on clinical need and priorities.

Although there continued to be high nurse bank usage, inspectors were encouraged to see that the bank nurses used came from a consistent pool of nursing colleagues who had an understanding of the environment and the patient group. 

We were also encouraged to see that where possible a family-friendly flexible working approach was being offered to nursing staff.  This is good practice. 

Inspectors were told that recruiting MHNs continued to be a challenge and that despite repeated efforts to recruit; the service had carried one Band 5 vacancy since February 2017.  We heard that the clinical manager had attended a recruitment event at Royal Cornhill Hospital (Aberdeen’s main psychiatric hospital) in an effort to recruit a new Band 5 MHN.  We were also informed that recruiting staff across NHS Grampian in general was currently a challenge, and the prison health centre is competing with all the hospitals in NHS Grampian when it comes to recruiting registered nurses.  

In the 2015 inspection we stated that nursing staff felt unsupported by their SPS colleagues to deliver care, and there was a general feeling among staff that they felt unsafe within the prison.  During the return visit we observed a definite shift away from this view by staff who told us that in general they felt safe working in the prison, and that relationships with SPS had improved considerably since the previous inspection.  That said, we noted that clinical staff had reported inconsistencies in the way that SPS officers managed incidents involving prisoners who were abusive to nursing staff.  Some immediately placed the prisoner on report whilst others did not directly intervene.  This is a situation that should be jointly addressed by local SPS and NHS management to ensure an appropriate and consistent approach is established.  However, staff were encouraged to escalate such incidents directly to their line manager if support from the senior management team was considered necessary.  This allowed the operational managers for the health centre and SPS to work collaboratively to reach an early resolution.  The senior management team were continuing to monitor this through Datix reports.

Primary Care

The inspection in 2015 highlighted issues with prisoners attending appointments in the health centre.  Staff frequently had to wait for up to one hour between consultations because SPS staff were slow to bring prisoners to clinics. 

Senior managers told us that although there had been a general improvement in the time taken to bring patients to the health centre for appointments, there could still be delays.  During the return visit, processes had been introduced to monitor waits and attendance to appointments.  In addition, the healthcare team were piloting the introduction of refusal slips, whereby if a patient does not attend their appointment, a member of the health centre team will visit that patient’s residential unit to find out the reason for their non-attendance and obtain the appropriate signature on the refusal slip.  The signed refusal slip is returned to the health centre administration team and recorded on a database.  By retaining an accurate record of why patients have refused an appointment will enable the healthcare team and SPS to take appropriate action in order to maximise the potential for the best outcome for the patient, as well as the best use of clinician’s time.  This is good practice.

In the 2015 inspection we highlighted that some external appointments were missed due to prisoners refusing to attend or transport by G4S being late.  Senior managers told us that there continues to be challenges with arranging for patients to attend external appointments.  To address this, the healthcare team were exploring the feasibility of digital and tele-health video consultations between the health centre and outpatient clinics at Aberdeen Royal Infirmary.  If successful this could reduce the movement of patients between the prison and acute/outpatient facilities, as well as reduce the need to bring clinicians into the prison.  In turn this should lead to a reduction in prisoners not attending clinic and appointments thereby improving access to services, support for staff.  This is an area of good practice. 

In addition we were told that using digital and tele-health video could also be used to support clinical supervision for staff.  

During the inspection in 2015 we reported that care plan documentation for prisoners with physical health needs was basic and not outcome-focused.  On the return visit we noted that further work was still needed to improve the quality of the care plan documentation.  Inspectors were told that a new band 6 practice nurse had been appointed to focus on improving physical healthcare documentation, as well as the development and management of long term conditions.  Inspectors were told that the practice nurse would work core hours and would link in with NHS Grampian’s lead nurse to develop care plans and implement long-term conditions clinics within the prison.

Patients told us that one of their main concerns was not receiving information on waiting times for appointments to services, whether these were within the health service or secondary care.  In response SPS and healthcare staff told us that they could take this forward as an action and provide accurate waiting times for services via the Prisons TV service. 

Infection Prevention and Control

During the 2015 inspection we reported clear weaknesses around the management of infection control; particularly around staff training, audit and staff awareness.  Although some work has been done since the last inspection, there is still considerable work to be done. 

The prison now receives input from NHS Grampians infection control team.  An infection control nurse now carries out onsite visits and can be contacted directly by anyone in the health centre for advice and support.  That said, no data for hand hygiene audits was available and we were told that there is no-one trained onsite to carry out local hand hygiene audits.  This was an urgent area for development. 

The infection control nurse told us that as the current models for infection control are aligned to community or hospital care, they do not always fit with a prison environment.  In response they were supporting the healthcare team to develop a ‘bespoke’ infection control model that aligns with prisoner healthcare.  Once developed this could potentially be shared across other prison estates and should be an area of good practice. 

Medication management

In the 2015 inspection we reported that the NHS Grampian controlled drug team had identified a need to train staff around the practice of checking of controlled drugs.  We were also concerned that the administration of medicines demonstrated a lack of compliance with best practice. 

During the return visit, we observed the administration of medication processes in the halls.  The process was safe and complied with professional and national guidance.  This was not the case in the Separation and Reintegration Unit.  Nursing staff did not ask the patient for their identification cards, or verbally ask for information about identification.  However, given they were attending each prisoner at their cell door, within a highly controlled environment they were aware of who they were. 

We witnessed one incidence when a nurse administered a controlled drug to a patient in the health centre without the second signatory being present.  We informed senior staff about our concerns and changes were immediately made to staff practices.  We were told that the prison continues to receive regular visits from 

NHS Grampian’s controlled drugs team; and that the most recent unannounced inspection in June 2017 had resulted in a staff training session immediately following the inspection and an agreed action plan.  Formal reporting and governance structures were in place, and progress against this action plan is reported to the AHSCP Clinical & Adult Social Work Governance Group.

Inspectors were told that due to staff turnover within the nursing team there were ongoing training requirements.  A lead pharmacist from NHS Grampian continues to work closely with the nursing and management teams in the health centre. 

A range of medication Standard Operating Procedures have been reviewed and updated by the clinical manager and lead pharmacist. 

Health Improvement

During the 2015 inspection we found little evidence of health promotion material being available within the health centre waiting areas, or of staff proactively delivering health promotion work. 

During the return visit we found improvements in the provision of health improvement literature, with a range of information booklets and self-help materials available for patients in both the health centre and the library.  Prisoners had access to NHSGrampian ‘health point’ in the library.  This is a one stop health information point that offers free confidential information and advice to prisoners.  This is good practice.  We were also told that a health improvement advisor offered a drop in service one day per week, whereby patients could discuss aspects of their health and receive advice.  Patient information booklets are given to prisoners during the induction process, and health centre literature runs through the loop throughout the prison’s TV.

In preparation for HMP & YOI Grampian becoming smoke-free, the prison has sought input and support by NHSGrampian’s public health team.  Smoking cessation advisors provide advice and support patients, SPS and health centre staff, as well as other teams in the prison.  This is a strength.

Mental Health 

Significant concerns were identified during the 2015 inspection regarding the provision of mental health services by the mental health team.  The concerns included;

• Not having a full complement of nursing staff to deliver mental health services
• Patients not being supported by staff to attend clinics
• Lack of one to one supervision access for mental health staff
• The lack of delivery of low level trauma interventions, brief psychological therapies such as anxiety or stress management.  
• The lack of formal assessment for mental health, care planning, communication with psychiatry and a lack of a clear triage system for referrals.

During the return visit, inspectors observed that the ability to deliver a comprehensive mental health service continued to be hindered by not having the full complement of nursing staff.  We were informed that NHS Grampian as a whole was experiencing significant challenges in recruiting to mental health nurse posts.

Senior managers told us that they were aware of the need to reshape the mental health workforce to support new models of care within the prison.  It was evident that understanding their patients’ needs was at the forefront and would directly inform plans to reshape the workforce to meet those needs. 

Despite not having the full complement of mental health nursing staff, support from senior nurses and substance misuse nurses, psychiatry, psychology, occupational therapist and currently a nurse consultant was allowing the service to be maintained. 

We were encouraged to see that developments were continuing particularly around assessment and care planning.  Patients referred to the mental health service are now triaged, and in addition to the ‘Talk to Me’ Strategy, the nurses on reception now completed a mental health screening document.

We observed the mental health team meeting which now provided the opportunity for case discussion with a psychiatrist to identify urgent cases. 

One member of the mental health team is currently attending clinical supervision training.  The nurse consultant currently provides supervision for mental health staff, which staff told us was supportive and provided an opportunity for development.

We were concerned that SPS staff did not always allow the psychiatrist to add additional prisoners to the list put in ‘add ons’ to his clinic, which resulted in the psychiatrist’s time being underutilised.  This concern was highlighted to senior managers.

Inspectors noted that care planning documentation had been widely developed since the inspection in 2015.  During our return visit we observed that this was just starting to be imbedded into practice.  Plans were in place for reviewing patients after three and six months.  We were told that different levels of care planning had been assigned different codes onto Vision.  Multi-disciplinary meetings were scheduled to discuss patients and their plan of care.  These were attended by the mental health team, substance misuse team, nursing staff, psychology, psychiatry and GPs.  This is good practice.

During the return visit we saw that access to psychological therapies was available for those patients identified as having complex needs.  A gap in provision for lower level interventions still remains.  We were told that a CBT therapist is to be recruited to develop low level psychological therapies within the prison.  Staff have also been identified to undergo training in low intensity core skills starting with coaching and motivational interviewing.  A training plan had been developed which identified further mental health and substance misuse staff to be trained in 2019, so that a ‘pool of staff’ are able to facilitate groups in coping skills and healthy living.  This is good practice.

Overall we saw a high level of enthusiasm to drive change to support service delivery.

We acknowledge the current limitations in delivering a comprehensive mental health service but recognise that significant progress has been made to improve the areas highlighted in the 2015 report.

Annex A: Inspection Team

Annex B: Acronyms