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8. HEALTHCARE
Outcome
Healthcare is provided to the same standard as in the community outside prison, available in response to need, with a full range of preventive services, promoting continuity with health services outside prison.
8.1 The provision of healthcare is good: facilities are excellent, although underused, and there is a developing mental health service. Some concerns are identified around the safe operating practices for controlled drugs. The addictions service is reactive, and the nurse triage system is not working effectively.
Physical Environment
8.2 The main healthcare facility is situated on the ground floor of the hub. It covers a large area and comprises waiting rooms, treatment areas, mental health and addictions offices, a dental suite, a physiotherapy area, prevalence testing areas, therapy rooms, multipurpose rooms, a vocational kitchen, and a pharmacy dispensing area. In 2005 the Inspectorate recommended "that the opportunity to make full use of a custom-built health centre should not be missed". Although it was evident that the facility has been used more, it still remains very under utilised and it is not used at all at weekends, when doctors visit the halls and see prisoners in less appropriate surroundings.
8.3 Healthcare rooms/offices in the residential areas require to be cleaned and broken equipment removed. No temperature control monitoring was evident on fridges where diabetic medication is stored. This was also the same in the main healthcare area where no temperature control monitoring had been undertaken in the three weeks before the inspection. This should happen every day. Privacy is poor in the healthcare room in reception, broken equipment was evident, and due to lack of a sluice area urine is disposed of in yellow bins. Outwith the hub area housekeeping/infection control should be improved.
Primary Healthcare
8.4 Healthcare is delivered by a team of 13 primary care nurses, four addictions nurses, three mental health nurses, two healthcare assistants, two pharmacy assistants and two administrators. It is overseen by two clinical managers (primary care and mental health) and a healthcare manager. Six staff vacancies meant that agency nurse support in excess of 25 sessions per week was required.
8.5 The medical team are employed by Medacs and consist of a pool of eight doctors delivering sessions daily Monday to Saturday. They also provide an on call service. To improve continuity and consistency of approach one doctor has taken the lead in addictions support. This is an area of good practice.
8.6 Nurses are available from 07.00hrs to 21.30hrs Monday to Friday and from 07.30hrs to 17.30hrs at weekends. The nursing team is split between primary and mental health service delivery. This is well organised and good flexibility was evident during staffing difficulties. All staff however voiced frustration at being able to deliver only the basics.
8.7 Nurse led clinics are delivered in diabetes, epilepsy, cardiac, bloodborne virus and sexual healthcare - when staff are available.
Secondary Healthcare
8.8 A dentist and dental nurse attend the prison one day each week. Facilities are good, and there are appropriate areas for dental decontamination. There was no waiting list at the time of inspection; the longest a prisoner would have to wait to be seen would be two weeks. The process for accessing dental care is via the nurse referral/triage form. Remand prisoners and prisoners in the last six months of their sentence only receive emergency treatment.
8.9 An optician attends the prison when there are a number of prisoners to be seen. A clinic had been delivered in the month prior to the inspection: despite this 47 prisoners were still on a waiting list. The waiting times to see an optician should be reduced.
8.10 A chiropodist attends the prison one afternoon every six weeks. Ten prisoners are listed to be seen during this session. Thirty three prisoners were on the waiting list: sometimes for up to four months. This should be reduced.
8.11 A Physiotherapist service is delivered one day each week. There is no waiting list for this service.
8.12 A Diabetic Clinic is delivered monthly by visiting specialists from the local NHS hospital. Throughcare arrangements with this team are robust with ongoing liaison and follow up in the community when a prisoner is liberated. This is an area of good practice.
8.13 The local NHS hospital delivers a monthly Bloodborne Virus and Sexual Health Clinic within the establishment. Caledonian Youth delivers sexual health education for prisoners under 25 years of age.
Mental Health Services
8.14 A Consultant Psychiatrist attends the prison for two sessions each week. This is flexible to meet demand and can be more should the prison require extra support. Links with external facilities are excellent. Three prisoners with acute mental health illness were transferred to hospital healthcare beds during the inspection.
8.15 A Multidisciplinary Mental Health Team meets regularly to discuss individual cases. Minutes are available. Prisoners with acute mental health needs are prioritised. Prisoners who self refer for mental health support may have to wait a significant amount of time for assessment or to see the nurse. Twenty five prisoners were waiting to be seen by this service: one prisoner had been waiting for 10 weeks.
8.16 Although there is evidence of a proactive mental health strategy and staff training programme, a number of initiatives were either at the implementation stage, had not yet started or were waiting for an increase in staff complement. Open Secret Counselling Service and Art Therapy Sessions are well established and prisoners spoke very positively about the support they received from these specialists. Joint working between PTI's and healthcare was evident and the session observed in the gymnasium for prisoners with mental health issues was extremely positive. This is an area of good practice.
Referral Process
8.17 Referral to healthcare is via self referral forms which are available in the residential areas. These are readily accessible in some areas, but in others prisoners have to ask an officer for one. This also applies to healthcare complaint forms.
8.18 The prisoner has to write down the reason why he wants to see a doctor. This is inappropriate, particularly when a nurse triage system is in place. A large number of confidential healthcare referral boxes have no padlocks and confidential self referral forms are sitting on desks in residential areas.
8.19 Nurse triage following referral is outdated. In one hall, referral forms were not being picked up every day. A nurse was also seen triaging/examining a patient through a grille gate in clear sight and sound of other prisoners as no healthcare room was available in the hall. This also occurred at the officer station. There is also no system in place to inform a prisoner when they will see the doctor/visiting specialist, despite the nurse arranging this on the day of triage. It is recommended that the referral system to see a doctor is improved and that full use is made of the health centre.
Management of Medicines
8.20 Medication is stored in line with current legislation. Prisoners are encouraged to keep their medication in their own possession. Administration times are appropriate. However, the process for ordering "as required" medication is part of the healthcare referral/triage process which increases the administrative burden and results in delays for prisoners. When this medication is dispensed to prisoners it is given out in the evenings at the officer stations in the residential areas. Prisoners line up and there is little confidentiality.
8.21 Nurse administration of controlled drugs is always undertaken by two qualified nurses. On some occasions the officer supporting this role was observing the route, organising prisoners going to work and answering the telephone.
8.22 One hundred and sixty prisoners were in receipt of a methadone prescription. Four prisoners were being prescribed suboxone, and three naltrexone.
8.23 The process for the transport of controlled drugs throughout the establishment does not follow safe operating practices. Nurses, with no officer escort, transport methadone from the health centre to residential areas, passing prisoners in main corridors. A safe system of internal transportation should be introduced.
Addictions
8.24 Substance misuse testing is undertaken by prison officers based in the health centre. The facilities for doing this are satisfactory. Outwith KPI testing 60-80 tests are undertaken each month for MDT or regime management purposes. Considering the number of people on methadone this seems low. Testing for compliance with medical prescriptions is not being done as often as required by the Healthcare Standards. The first urine sample taken in reception is not observed by the nurse on duty.
8.25 There is no full-time Addictions Co-ordinator in post. The Healthcare Manager oversees this role alongside other duties. She regularly attends the SPS Addictions Co-ordinator Forum and there is evidence of feedback to the local Substance Misuse Policy Meeting ( SMPM). This bi-monthly meeting is chaired by the Deputy Governor. Minutes are available and widely circulated. The prison is well represented on local Drug Action Teams by members of the SMPM.
8.26 A weekly Addictions Case Management Meeting is held to discuss individual cases. This is well attended by Phoenix Futures, the addictions/mental health nurse, the senior healthcare manager and the doctors.
8.27 The Phoenix Futures team comprises a team manager, senior practitioner, four caseworkers and one administrator. There was one vacancy at the time of the inspection. The team is based in the hub, and facilities are excellent. The team is well integrated within the prison and has established excellent community links. They deliver group work and individual support in relation to drugs, alcohol and smoking as required by the SPS Addictions Contract. They were not delivering a pre-release harm reduction session for remand prisoners. There is adequate information about the team in the residential areas, although referral forms are not readily available. Waiting lists are evident for some interventions. The team delivers a weekly family awareness session. This is an area of good practice.
8.28 An Addictions Support Area opened in Ratho Hall just before the inspection started. Nineteen prisoners were living there. Although this is a welcome development, no interventions were in place at the time of the inspection, and some of the prisoners living there did not meet the stated entry criteria.
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