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8.1 Health care in the establishment was overseen by a Health Care Management Group. This Group was chaired by the Deputy Governor and included the health centre Manager, psychiatrist, MO, Social Worker and psychologist. The Group met every two months and discussed a wide range of health issues including the working of the ACT protocols. At the end of each meeting it routinely discussed ongoing problems with any YO/prisoner who was considered a suicide risk.
8.2 The health care centre was accommodated on one floor within the main part of the Institution and had an L-shaped design. Separated by a door from the main health centre was a waiting area which was spacious but spartan. There was bench seating and a wide range of health promotion material in custom designed holders on one wall.
8.3 Along one arm of the L-shape was a large consulting room in which there was an examination couch and lamp, as well as specialist eye examination equipment for use by the optician. It was appropriately furnished and also contained current medical records in custom designed shelving. Adjacent to the consulting room was the treatment room which was also of a generous size and had a stable-type door which facilitated the dispensing of medications by the practitioner nurses. There was an examination couch but no lamp, though it did contain all the required emergency equipment, including a special burns pack. This emergency equipment was checked on a monthly basis by a member of the nursing team. Topical treatments were held in this room in a lockable cabinet.
7.31 Opposite the treatment room was the nurses' office in which there was a SPIN terminal. Attached to this office was a room that was used as a pharmacy where the main part of the drugs stock was contained in steel cabinets. Current prescriptions were, however, held in a drugs trolley in the treatment room. Also in this area were a small store room, the staff toilet facilities and a small but adequate interview room which also served as a medical library.
7.32 Along the other arm of the L-shaped was a large store room that was used for storing old records and any other items not currently in use. Next to this was the dental suite and four cells, though the latter were no longer in use. There was also an ablutions area that currently was being used to provide toilet facilities for YOs/prisoners attending the health centre.
8.6 The only other area where YOs/prisoners were routinely examined, other than in emergency situations, was in reception, where the facilities consisted of a well-appointed room set apart from the main area of activity. Nursing staff carried out their initial screening of newly arrived admissions in this well equipped and sound proof room. In addition, the reception area had video facilities which allowed, for example, the screening of suicide awareness videos.
8.7 Given the size of the establishment, the medical accommodation, which was being redecorated during our visit, was adequate for its purpose. We suggest, however, that the facilities could be improved with some relatively minor changes. For example, the small store room and staff toilet could be adapted for the testing of urine samples when the national detoxification programme is implemented. If this were done, the ablutions area near the cells could then be converted with the addition of a shower facility for use by staff. In addition, a second interview room could be provided if one of the unused cells was converted for that purpose. This would then free the consulting room which was frequently used by visiting professionals for interviews, thereby denying staff access to the medical records.
8.8 As far as medical equipment is concerned, we felt that on the whole this was adequate though some of it was beginning to show signs of age. We understand that arrangements had been made to upgrade the relevant items though we have written to the Governor suggesting that the treatment room would benefit from the addition of an inspection lamp. The nurses' office should also have a shredder and photocopier (though we understand that these are to be provided in the near future).
8.9 The facilities for the medical examination and mental health screening of prisoners in the reception area were excellent. They were ideal for interviewing prisoners at what can be a critical time in the assessment of their vulnerability.
8.10 The MO was a partner in one of the local general practices and when he was not available, one of his partners carried out his duties. He attended the Institution every morning from 0830 to 0930 to carry out a surgery and to see any new admissions. He also attended on Saturday mornings but only for the purpose of seeing admissions. At all other times he was on call for emergencies either to attend or if appropriate, to give advice to the nursing team. He attended meetings of the Health Care Management Group.
8.11 The MO had trained for general practice in the local area which meant that he was very familiar with the way the local hospitals operated and he knew the various Consultants well. Consequently, we were told that relationships were good and that the establishment experienced no problems in obtaining second opinions or prompt specialist treatment. The MO's working relationship with the other members of the health care team also appeared to be very good.
8.12 The MO expressed general satisfaction with the way health care was delivered in the establishment though he was concerned that certain items of medical equipment were in need of renewal -; see paragraph 8.8. He also expressed concern about the implications of the proposed introduction of the new national drug detoxification programme. Currently the policy which he adopted, which involved working closely with Cameron House - a community addiction unit - was to detoxify addictive prisoners with methadone if they were on a community programme and to use symptomatic treatment for others. He was of the opinion that this worked well in the context of Dumfries.
8.13 In our view, the Institution appeared to be fortunate in the medical cover it received. The MO was committed to his work in the establishment and he and his partners saw the work as very much an extension of their general practice. This view is wholly commendable and helps to ensure that YOs/prisoners receive a high level of primary medical care. We were also pleased that the MO attended on a Saturday morning to see admissions, so that they were not left waiting over the weekend.
8.14 We do not feel competent to comment on the MO's concerns about the implications of the proposed drug detoxification policy.
8.15 The nursing team consisted of a clinical supervisor and three practitioner nurses, though there were plans to appoint an additional practitioner nurse to facilitate the implementation of the proposed national drug detoxification policy. It was considered locally that this extra member of staff would also allow an adequate level of nursing input to the new observation suite for vulnerable YOs/prisoners, whenever this was required. The health care centre had nursing cover from 0715 am to 2130 hours and at weekends from 0730 to 1700. As well as their general medical care duties, the nursing team was also involved in the implementation of the ACT strategy.
8.16 Two members of the nursing team were RGN trained and two had Registered Mental Health Nurse qualifications. We were pleased to learn that every encouragement was given to members of the nursing team to attend professional and staff development courses, a situation that had been helped by the appointment of a fourth member of the nursing team during 1998. We were told also that the relationship between line management and the nursing team was very good, whilst the impression that we gained was that there was also a good rapport between health care workers and Discipline staff.
8.17 There were nurse-led clinics operating for those who had skin problems as well as for asthmatics and we were advised of plans to develop other clinics. The nurses also saw mental health as an important area of their activity and it was partly for this reason that mental health referral forms had been developed -; see paragraph 8.18. The team was keen to be involved in preventive medical activities and had made a range of literature available to YOs/prisoners. Recently, a programme of immunisation against Hepatitis B had resulted in an uptake rate of more than 75% and follow-up immunisations had also been arranged. The vaccine was also being offered to all admissions who arrived after the original programme.
8.18 The nursing team had also introduced two interesting changes. Firstly, as noted above, a special referral form was being used for anyone concerned about the mental health of any YO/prisoner. We saw examples of some of these being processed, the forms in question having been filled in by Hall staff who had had concerns about certain individuals. We were impressed by the way this had been done. Secondly, the nursing team had proposed and implemented a coding system for emergency calls in the establishment. A red code indicated a medical emergency involving blood loss, whilst a blue code was an indication that the problem was due to asphyxiation. This system was intended not only to preserve confidentiality but also to ensure that in an emergency, appropriate equipment was brought to the scene for immediate use.
8.19 One area of activity which did appear to cause problems was the provision of escorts for those attending the health care centre. This is discussed in more detail in paragraph 8.21.
8.20 We were impressed by the dedication and commitment of the members of the nursing team. Since the appointment of the clinical supervisor in 1998 there were clear indications that the health care team had adopted a proactive role in developing its work within the establishment. The use of the new mental health referral forms and the introduction of the emergency codes were indications of thought having been given to ways of improving the level of service being provided. We were also pleased at the way the team had successfully introduced the Hepatitis B immunisation programme and its achievement of such a high uptake. The team was anxious to develop more nurse-led clinics and to become more active in areas of health promotion. An additional member of the nursing team, as proposed, would undoubtedly help in this regard, including more involvement in the local ACT strategy.
8.21 We were concerned, however, over the fact that a number of staff connected with health care spoke to us about the problems of obtaining escorts for patients to and from the health centre. This was leading to delay and frustration and was wasting the time of professionals, who had only a limited period in the Institution in which to carry out their work. If this situation continues, the opportunity to expand the work of the nursing team in the health care centre is likely to be limited. We suggest, therefore, that senior management should consider ways of improving the provision of Discipline cover for the health centre. Such cover need not be for the whole working day but rather, it could specifically cover clinic periods. We see this as a priority which, if resolved, would greatly enhance the way health care could be developed in the establishment.
8.22 Drugs and topical applications were kept separately, the former in steel cabinets in the room attached to the nurses office whilst the latter were kept in the treatment room in appropriate lockable units. Similarly, controlled drugs were kept in a suitable locked cabinet in the room next to the nurses station which acted as the pharmacy. All drugs that were currently being dispensed were held in a custom designed medicine trolley which was kept in the treatment room.
8.23 The Institution did not use a drug formulary but generic drugs were prescribed where possible. From what we saw during the inspection, we were satisfied that the pharmacy stock was being maintained at the lowest possible level consistent with good practice.
8.24 Supplies for the pharmacy were obtained under contract from Dumfries Royal Infirmary. This appeared to be a very satisfactory arrangement and items were obtained promptly and at minimum cost. All pharmacy stock was checked monthly. It was the policy to return unused drugs, including controlled drugs, to Dumfries Royal Infirmary for disposal.
8.25 The MO normally wrote prescribed drugs in a Kardex for each individual and the drugs were then either ordered from the hospital pharmacy or made up from stock by the nurse. In all cases, however, the nursing team was involved in secondary dispensing duties. Drugs were normally issued up to four times daily and in the majority of cases, the individuals concerned attended the health centre and took the drugs under the supervision of a nurse whilst standing at the half door of the treatment room. As the final issue was after the evening lock up, the nurse was required on that occasion to issue drugs in the Halls. At weekends, however, as nurses were not available for the late shift this task was delegated to Residential staff, the doses having first been made up by a member of the nursing team.
8.26 The pharmacy arrangements appeared to be satisfactory, except for two aspects. The first was the continued use of nursing staff for secondary dispensing duties, though this should be resolved when new national arrangements are introduced. The other concern was the use of Residential staff at weekends to hand out drugs, though this could be solved if an additional nurse is appointed -; see paragraph 8.15.
8.27 Medical records of all those currently in the establishment were filed in alphabetical order on shelving in the MO's consulting room. Historical records were stored separately in alphabetical order in the general store room. Nursing and medical staff, including the consultant psychiatrist, all contributed to the records which were in the SPS standard design and included ACT documentation.
8.28 Information on health care activity was maintained in a number of registers. The numbers of those seen by the nursing team and the MO were about the same and fluctuated between 100 and 200 per month, some of that variation being due to the population turnover. In addition to those seen in routine daily clinics, an extra 10 to 15 were seen each month as emergencies, mainly due to physical injuries. In the year preceding our inspection, there had been 18 admissions to hospital for inpatient care whilst 116 had been seen in hospital outpatient clinics. The numbers referred to the visiting psychiatrist varied between 240 and 300 per year.
8.29 In the year prior to our inspection, the number of prescriptions issued had been approximately 360 in addition to which, 960 repeat prescriptions had been issued during the same period. Also, during the course of the year, 48 individuals had been identified as having some serious medical problem -; viz, 30 asthmatics, 12 epileptics, 3 diabetics and 3 with cardiovascular conditions.
8.30 YOs/prisoners were all given the opportunity to undergo screening for blood borne diseases and 16 had accepted that offer. All had received pre-test counselling and the one individual who had tested positive for Hepatitis C had been given post-test counselling.
7.31 We analysed the random sample of the medical records and were content that they had been properly completed and were being well maintained. We were also satisfied that the newly introduced referral forms appeared to contain all appropriate information.
7.31 We were content that the establishment's medical records were being satisfactorily maintained (though some of the covers of the records were beginning to show signs of wear and tear).
8.33 We were pleased to note the way the referral forms were working and commend this as a practice that other establishments might wish to consider adopting. It was also reassuring to receive statistics of health care activities in the Institution.
8.34 A consultant psychiatrist from Crichton Royal Hospital attended the Institution twice weekly and had been involved with the establishment for five years. He also involved his Registrar in some of this work and his colleagues at the Hospital provided cover when he was unavailable. He was a member of the Health Care Management Group.
8.35 The psychiatrist said that he had a good working relationship with the other members of the health care team. Although he was not able to meet with some of his colleagues as often as he would have liked, he felt that everyone communicated well and there was a good rapport among all the professionals.
8.36 He was also content with the way health care was organised but did have two concerns. The first related to escorts and the problems there appeared to be in making arrangements for patients to arrive at his clinic on time, which resulted in unnecessary delays -; see paragraph 8.21. Additionally, he referred to the Female Unit, from where he had a very high consultation rate. He felt that their mental state would be helped if they were to be more fully occupied. In addition, the Unit had only one anti-ligature cell which meant that the facilities were not ideal for the management of women who might be at risk of self-harm -; see also paragraph 4.39.
8.37 The dentist was unavailable for interview during the course of our inspection and we therefore relied on other members of the health care team for information about the level of service.
8.38 The dentist had a weekly session in the Institution from 0900 am to 1200 hours on Thursdays. At the time of our inspection, the dental suite was in the process of being refurbished and had recently had a new dental chair installed, together with all the necessary associated equipment. As part of that refurbishment, new built-in storage cabinets and working surfaces were being installed and once this work was completed the dental suite should be very satisfactory.
8.39 We were advised that in the recent past, there had been some problems with the dental surgeon's waiting list but this had been resolved by some extra surgeries. At the time our inspection, the waiting list totalled four.
8.40 As with other areas of health care in the Institution, one of the problems that the dentist had in attempting to deliver an efficient service appeared to revolve around the provision of escorts. Apart from delays in patients arriving during the session, there was also a problem when an escorting officer was obliged to return to the Halls at 1130 hours for meal duties. This prevented the dentist from working the full session and consequently, it meant that he was treating fewer patients than he otherwise would have been able to do.
8.41 An optician attended the Institution on an as required basis, whilst those requiring chiropody treatment were referred to community facilities.
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