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8.1 Health care was based in a purpose built unit in the centre of the prison. Strong links had been established with the Psychology Department, which was located on the floor above.
8.2 The organisation of the health care team was unusual for a Scottish prison in that the Clinical Manager, who was a nurse, was the line manager for all members of the health care team including the MO. In practice, the working relationship between the MO and the Clinical Manager was one of partnership. The interface between the Health Centre and the rest of the prison was assisted by the Health Centre Manager being a member of the Director’s management team.
8.3 When the prison opened, the only member of the health care team, including the MO, who had experience of working in a prison environment was the Clinical Manager. This situation had placed considerable responsibility on him to support his staff and ensure that the health care team maintained a non-judgemental approach to the care of prisoners. As far as we could assess, this had been achieved despite the high turnover of nursing staff.
8.4 Prisoners who wished to have a routine medical consultation with the MO or members of the nursing team completed a Medical Application Form. In addition, specialist hospital advice was provided by medical and surgical consultants who attended the prison as necessary.
8.5 In line with other areas of the prison, the delivery of health care services had in place a series of Director's Rules (see paragraph 9.21) that served as policy and procedural guidance for the Health Centre Manager and the team.
8.6 The Health Centre was based on the ground floor of the Amenities building, which also housed the Psychology Department, the Education Department and the staff training areas. The design was based around a corridor that formed a rectangle. The various rooms, the ward area and the storage areas opened on to this corridor, which was rather narrow. Very few of the rooms had windows and the ward area, which did have windows, had a view that was restricted by a high fence. The ward area had 16 beds and was divided into 4-bedded wards; there were also two single rooms. Near the wards was an association area, which had a telephone and television as well as a toilet with glass panelling. Next to the association room was an area with a bath and showers for the use of in-patient prisoners. There was also a kitchen for prisoners’ use. Adjoining the wards was a roofed exercise area for the use of ambulant in-patients.
8.7 The nursing team was based in a narrow office with a window overlooking the ward area. There was a CCTV monitor in this office, which gave a view of other parts of the Health Centre. The nurses’ office contained a SPIN computer and a PPS terminal. Leading through from the nurses office was an area that held the medical records on open shelving.
8.8 The Clinical Manager had his own office opposite the MO’s office; the Assistant Clinical Manager’s office was adjacent. The remainder of the Health Centre was given over to the consultation and treatment facilities, which included three consulting rooms, a treatment room, a trauma room, a dental suite, pharmacy and a variety of storage rooms. There was also a radiology room that contained x-ray equipment.
8.9 All the rooms were well equipped. In particular, the treatment and trauma facilities were fitted out with a range of modern equipment for routine treatments as well as emergency resuscitation. There was a waiting area for prisoners, which was divided into two rooms separated by a wall, which contained a large glass panel. Facilities for staff included a shower room and a kitchen.
8.10 The medical room in Reception was well furnished and included a wash hand basin.
8.11 The design of the Health Centre was functional but the combination of a narrow corridor, very few windows and small rooms created a real feeling of claustrophobia. A commendable effort had been made to brighten up the area with plants but there was a lack of natural light and ventilation. It was noticeable, for example, that a fan was permanently on in the MO’s small office.
8.12 Generally, the layout and design of the Health Centre mitigated against good observation and lines of sight. Conversely, we were of the view that the number of observation panels in doors was inappropriate – e.g. in treatment rooms and the toilet in the association area, which exposed individuals unnecessarily to public gaze.
8.13 At the time of our inspection, one of the single rooms had been wrecked by a prisoner. We understand that this was not an unusual occurrence. This raised doubts, therefore, as to whether these rooms were being used appropriately and whether a prisoner who is mainly intent on destroying his environment is best placed in a Health Centre. This is a situation that we believe management should monitor. We noted also that the prisoners’ waiting room was rather bare and unwelcoming and were told that it had repeatedly been vandalised by posters being ripped off the walls and graffiti.
8.14 The MO had a full-time appointment, though he did have some outside work as a police surgeon and in an accident and emergency department.
8.15 His clinics, which were a combination of appointments, urgent cases, new admissions and reviews, were held every weekday in the Health Centre and could last up to three hours. All newly admitted prisoners were seen by the MO in the Health Centre within 24 hours of admission, when they were offered appropriate Hepatitis B immunisation. The average waiting time for non-urgent cases to see the MO was three days.
8.16 As well as a physical check, the MO carried out a psychiatric evaluation of all new prisoners, in line with the structured medical admission assessment form that he then dated and signed. He was also involved in the work of the mental health team and the drug detoxification programme and worked closely with an infectious diseases consultant to supervise the shared care protocol for the management of blood borne virus diseases. He also carried out minor surgery, as well as the medical supervision of patients in the 16 bedded ward area.
8.17 We were impressed by the obvious commitment and enthusiasm of the MO, who had previously worked in the local area in general practice, accident and emergency, psychiatry and as a police surgeon. This had enabled him to establish close links between the prison and the local community medical services.
8.18 We were pleased to see the good relationship that he had with his line manager – see paragraph 8.2. This is an unusual arrangement and virtually unknown in a primary care environment, but it was working well and meant that the MO could concentrate on his clinical work.
8.19 It was clear that the doctor had a good working relationship with his nursing colleagues in the Health Centre as well as with the senior psychologist, with whom he was also required to work closely as part of the establishment’s anti-suicide strategy. We have earlier referred to the protocol for the management of blood borne virus diseases and the MO had a pivotal role in this, which he had embraced enthusiastically. We were pleased with this development in view of the fact that the management of patients with Hepatitis C is becoming an increasingly important part of prison health care, as the numbers of known cases rise.
8.20 The MO had also maintained a certain amount of outside work, which had helped him to maintain a breadth of knowledge and interest, which we believe is important. Finally, his links - along with other members of the team - with the public health department and the community drug addiction unit are to be commended.
8.21 The nursing team was supervised by the Assistant Clinical Manager and when all posts were filled, comprised 13 nurse practitioners. At the time of the inspection, there was one vacant post and two nurse practitioners were on long-term sickness absence. Four nurse practitioners held an RMN qualification.
8.22 Systems for maintaining good communications were in place. In addition to the prison briefing programme, a fortnightly meeting between the Health Centre Manager and health care staff had been established; this provided a useful opportunity for discussion, updates and staff training.
8.23 Only two of the team of nurses employed at the opening of the prison were still in post at the time of the inspection; this suggests that the retention of nursing staff is an issue to be addressed. It was evident that pay had been a major consideration.
8.24 Whilst there was evidence of team building, the scope for team development would be enhanced if a more stable workforce could be established.
8.25 Nurse practitioners were engaged in the health assessment of all admissions to the prison. They also undertook a daily triage of those prisoners who reported ill health and provided a nurse treatment service for those who could be treated within the competence of a nurse practitioner. They provided an emergency response to accidents, assaults, self-harm or acute illness and an excellent response time to emergencies had been achieved. Some difficulties had been experienced in getting patients to the Health Centre for treatment and this had caused frustration for prisoners and nurse practitioners.
8.26 In-patient hospital care was provided for those admitted to the Health Centre. Nursing care plans were in place and supporting documentation and records were good.
8.27 Chronic disease management was being established, with different nurse practitioners managing different disease groups. Where nurses had been given this responsibility, it not only benefited the patients but the nurses also enjoyed the increased job satisfaction.
8.28 Nurse practitioners had been engaged in a clinical audit to ascertain the degree of drug use amongst prisoners. The findings reflected the serious drug problem in the West of Scotland and had been useful in informing those working on the drug strategy for the prison.
8.29 In general, nursing practice was being carried out in a competent and professional manner and there were opportunities for expanded nursing roles. A long-term strategy for training had yet to be formalised but the training needed to meet current deficiencies in skills and knowledge was being addressed. Nurses were supported in achieving the requirements for continued registration, as set out by the United Kingdom Central Council for Nursing, Midwifery and Health Visiting.
8.30 The pharmacy was a rather small and cramped room. As well as containing the pharmacy stock on open shelving, it also contained the two trolleys that were used to distribute prescribed medication to the two Houseblocks and the segregation unit, a lockable refrigerator and a cabinet for dangerous drugs. The nurses used a Kardex for the monitoring of prescriptions. There was a hatch in the door through which supervised medications were handed out to prisoners, including those who were involved in the detoxification programmes. A community pharmacist attended weekly to check prescriptions and monitor stock.
8.31 The prison had produced its own formulary, taking into account general practitioner and SPS guidelines. From our review of the formulary, it seemed sensible and comprehensive within a prison context and acknowledged the need for clinicians to have choice in the treatment of particular patients.
8.32 The contractual arrangement with the local pharmacist ensured that all patients who were able to self-medicate had their prescription dispensed by the pharmacist via a container that gave the patient's name and prescription details. This is in line with SPS's pharmaceutical guidance. However, other patients who required supervised medication had their medicine administered by a nurse directly from a stock bottle. Whilst this arrangement is not wrong, it is different from that which operates in other SPS prisons, where the majority of supervised medications are now administered by a nurse from each patient's own personally named bottle/container. The SPS arrangement therefore provides an additional check for those administering the medicine.
8.33 Plans were being made to discuss with the local pharmacist the possibility of prescribing information being available to the Health Centre Manager. This information would be needed to monitor and review prescribing.
8.34 The pharmacy appeared to be well organised, though we would have preferred to have seen it in a larger room. It relied on manual information, whereas we felt that it could benefit from having a modern, computer-assisted monitoring system. Also, in spite of its very good formulary, it still appeared to be carrying a lot of stock. This may well be justified by demand but it is something that staff may wish to review.
8.35 Notwithstanding that local management considered that it would be impracticable to have all supervised medication made up individually, we believe it would be prudent to keep these arrangements under review in order to ensure that they provide the maximum quality and safety standards.
8.36 Medical records were stored on open shelving in an area linked to the nurses' office and were of the standard A4 format. In addition to the usual medical information, such as clinical notes, investigations and correspondence, the records included prisoners’ photographs.
8.37 The prison used a customised medical admission assessment form, which was simple but clear. The design of the form paid particular attention to assisting the examiner to highlight any psychiatric risks, through a comprehensive check-list of risk factors. In addition, there was a specially designed and structured emergency hospital referral form. This set out the relevant important information about prisoners and details of any medical actions already taken prior to the transfer from prison to accident and emergency department.
8.38 The medical records also contained, where appropriate, a set of shared care forms, specially designed as part of the management of patients who were infected with a blood borne virus, particularly those who were Hepatitis C positive. The data set included all relevant information, as well as a counselling check list. It also contained progress charts for monitoring data and a sheet for the consultant’s comments and advice. Various registers were also maintained for a variety of health care activities relating, for example, to drug detoxification, optician clinics and chiropody clinics, as well as out-patient referral arrangements.
8.39 The health care team produced comprehensive monthly statistics regarding the activity of the health centre. A study of these statistics for the period March 1999 to February 2000 showed that apart from all newly admitted prisoners, who were seen within 24 hours of admission, the MO saw on average 300 cases every month – equivalent to 58% of the prison population. By the same token, the nurses in the process of triaging prisoners who reported sick daily, saw a proportion that represented on average 82% of the prison population over the year. In the three months prior to our inspection, that average had risen to the equivalent of 102% of the population, a significant and heavy workload that should be monitored closely and analysed to establish causes.
8.40 At the time of our inspection, 51% of the prisoners were on some form of medication. Of this total, 9% represented repeat prescriptions – i.e., medication taken for chronic conditions. Out of the total number of prisoners on medication, just under half were provided with a course of treatment (usually for a week) and took their medication without supervision. The remainder were given their medication under supervision by members of the nursing team.
8.41 During the 12 months preceding our inspection, 26 prisoners had been admitted to hospital, 200 had been referred to medical or surgical specialists and 76 had been referred to the mental health team, with three of those prisoners having been transferred to a psychiatric hospital.
8.42 Through testing, 41 prisoners had been shown to be positive for Hepatitis C and two for Hepatitis B. The immunisation rate for completed courses of Hepatitis B was 11.6%.
8.43 The establishment’s medical record system was well organised. Additional features of the system were the use of prisoners’ photographs, the initial assessment form, the emergency hospital referred form and the data set associated with the shared care of prisoners with blood borne virus conditions. All of these we consider to be examples of best practice.
8.44 We were also impressed by the comprehensive monthly statistical output of information relating to the work of the health care team. The statistics showed that the team had a high level of prisoner contact, with high consultation rates for both nurses and doctors. A further improvement could, however, be achieved in the provision of morbidity information if a computerised medical information system were to be introduced.
8.45 It was encouraging to see that, where possible, prisoners were given their weekly supply of medication and we were also pleased to note that since February 2000, the monthly health care statistics included information on nurse-led clinics.
8.46 Nurse practitioners who were already RMNs engaged with other health care professionals, such as the MO, clinical psychologist, counsellor and social worker, in one-to-one casework with those who had mental health problems. A forensic psychiatrist had been appointed four months prior to our visit. A multidisciplinary team had therefore been formed and whilst this method of working was in the early stages of development, it promised to deliver benefits to patients by a co-ordinated approach to service delivery and the avoidance of duplication and conflicting advice.
8.47 Psychiatric services to the prison were provided by a consultant psychiatrist from Ailsa Hospital, Ayr. Prior to the appointment of the current postholder, psychiatric support had been provided by a group of psychiatrists working on a rota system. However, those arrangements had changed in November 1999 to the current system whereby the six hours of provision each week was divided into two sessions of three hours, where up to six prisoners could be seen. At the time of our visit, one of the two weekly sessions was taken by the consultant and the other by a specialist registrar in forensic psychiatry. Both psychiatrists entered details of consultations with prisoners in the mental health section of the medical records. In addition, they routinely wrote follow-up letters to the MO, which were also included in the medical records.
8.48 The psychiatrist informed us that he had regular contacts with the MO, from whom he received most of his referrals. The remainder of the referrals were from nursing staff. He said that he had little contact with the Psychology Department and was not a member of any specific groups (e.g. the At-Risk Management Team). During the time he had been working in the prison, he had not felt the need for additional support from psychology colleagues. He was aware that on occasion the senior psychologist, who was trained in forensic psychology, saw individual prisoners if this was thought to be appropriate.
8.49 The psychiatrist said that there was a relaxed atmosphere in the Health Centre and as far as he could judge, a good relationship existed amongst the health care staff. He was of the opinion that the current arrangements for providing the health care team with psychiatric advice were satisfactory and he believed that there was sufficient service provision to cope with prisoners’ mental health requirements. He confirmed the impression that we had gained from studying the medical records that the establishment had been obliged to manage some extremely difficult individuals. He said some prisoners displayed quite disturbed behaviour, which was associated with complex psychiatric or possible psychiatric problems. Consequently, considerable demands had been made both on discipline staff and the health care team to try and cope with these individuals.
8.50 The psychiatrist did not have a view on the use of the single rooms in the Health Centre, since he had not been directly involved in the management of patients admitted to those rooms. He did, however, have some concerns about safety when dealing with what he regarded as potentially dangerous prisoners. He was of the view that the design of the Health Centre did not promote feelings of confidence about personal security.
8.51 There were two other concerns, the first of which related to the type of support that the prison received from the State Hospital. He felt that there were occasions when the establishment had been obliged to look after prisoners who would be more suitably managed in Carstairs. Secondly, he was worried that potentially dangerous prisoners were discharged back into the community where there was, in his view, no proper provision for these individuals. Although community psychiatric services were providing some support, he perceived a need for a medium risk secure unit in the community.
8.52 Mental health provision appeared to be satisfactory. There had clearly been a recognition of the need to develop a team approach to mental health care and continuity of the management of psychiatric services to the prison had been improved with the introduction of the current arrangements. However, the concerns expressed by the psychiatrist about personal security in the Health Centre should be addressed as a matter of urgency.
8.53 A dentist from a local general dental practice attended the prison for nine hours a week spread over three sessions. He brought his own dental nurses to assist him in his work and having more than one nurse had allowed him to organise his own appointment system. On average, he saw about 120 patients each month. Dental work was carried out in a small, rather cramped but well equipped dental suite, which included x-ray equipment.
8.54 The dentist had a policy of keeping a duplicate copy of prisoners’ dental records in the medical records, which were available to him when he saw his patients.
8.55 From our observations, there appeared to be a high standard of infection control in carrying out dental work. We also saw evidence of the good working relationship between the dentist and Health Centre staff. He also clearly demonstrated a good rapport with his prisoner patients.
8.56 We were impressed with the arrangements for dental care in the prison. We noted that in common with other health care providers, the dentist also encountered delays in getting patients to his clinic on time and this is a situation that should be looked at by management.
8.57 At the time of our inspection, the dentist waiting list was short but we understand that if required, he was always willing to put in extra time to keep the waiting list within acceptable limits.
8.58 We were particularly impressed by the protocol that the dentist had introduced to insert a copy of the dental record in prisoners’ medical records. This is taking advantage of the fact that it is possible to integrate the medical and dental care in a prison environment in a way that is not possible in the community. It seemed to us to be a very sensible policy and one that we strongly commend as best practice for prison medical and dental care. A dental record sheet could, for example, form part of the standard medical record.
8.59 In addition to the medical provision described above, the prison employed a physiotherapist, chiropodist, optician and radiographer.
8.60 The physiotherapist was contracted for six hours a week and at the time of our inspection, had a waiting list of 26. The chiropodist attended for three hours each month and had a waiting list of seven. The optician also attended for three hours a month and had a waiting list at the time of our inspection of 15.
8.61 Radiography services were provided by staff from Crosshouse Hospital. The radiographer attended routinely for half a day every fortnight but the prison had an arrangement under the contract that allowed for four emergency calls each month if required. On average, the radiographer took nine x-rays every month, the range being between six and 15. All x-rays taken were checked by a radiologist from the Hospital.
8.62 We formed the impression that the ancillary medical services for the prison were generally adequate. However, the workload of the optician and the physiotherapist should be kept under review to prevent the waiting time for consultations going beyond reasonable limits.
8.63 We were most impressed with what had been achieved in the Health Centre in such a relatively short space of time. In particular, the Health Centre Manager is to be commended for his excellent leadership and management. A good interface between the Health Centre and the rest of the prison was also evident.
8.64 We were particularly impressed with a number of innovative features - for example, the excellent patient information systems, the concentrated effort to achieve a co-ordinated approach to mental health care and several other examples of best practice, not least the protocol whereby dental information is inserted into prisoners’ medical records. Similarly, we were impressed with the level of contact between health care staff and prisoners and the number of prisoners who said they were satisfied with their treatment.
8.65 Overall, the operation of the Health Centre was as impressive as any we have seen in a Scottish prison. In direct contrast, however, its accommodation was cramped and claustrophobic and in our opinion, appeared to suffer from a number of fundamental design shortcomings that were impacting adversely on a number of areas.
8.66 However, the priority is for the health care team to consolidate. In particular, it will be necessary to address the high turnover of nurses if the high standards achieved are to be maintained.
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