We carried out an announced follow up inspection of healthcare services provided by Central and North West London NHS Foundation Trust (CNWL) at HMP High Down on 23 and 24 May 2022. This was in response to a focused inspection carried out in June 2021 when we found the quality of care required improvement. We issued a Requirement Notice in relation to Regulation 17: Good governance. Systems and processes did not always ensure the maintenance and quality of care.
The purpose of this focused follow up inspection was to determine if the healthcare services provided by CNWL were now meeting the legal requirements of the above regulation, under Section 60 of the Health and Social Care Act 2008.
We do not currently rate services provided in prisons. We highlight good practice and issues that service providers need to improve and take regulatory action as necessary.
At this inspection we found:
- Systems for monitoring storage temperatures of medicines were effective.
- Systems for checking items stored in emergency bags were effective.
- Medicines administration was undertaken in line with policies and procedures.
- A monthly missed dose report enabled analysis and service improvements to be implemented.
- There was a high number of vacancies in the physical health care team, however, there was a consistent team of bank and agency staff.
- Safe staffing levels were reviewed on a daily and weekly basis, however, there was not an effective system to readily report on the number of unfilled shifts over time.
- There was a system in place to monitor the use of, and response to, ‘Tasks’ within the electronic patient record system in line with agreed processes and procedures.
- Compliance with secondary health screenings within seven days was good and systems enabled a further health screening appointment to be routinely offered when an initial appointment had been missed.
- Waiting lists were continuously reviewed to enable patients with the highest need to be prioritised for care and treatment.
- Staff received adequate mentoring for their role.
- Most, but not all staff received supervision in line with the provider’s policy.
- Newly appointed staff received an induction and most, but not all, staff felt supported in their roles.
- Systems were not effective in ensuring the management of patients with long-term health conditions.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure systems and processes are effective in ensuring patients with a long-term health condition receive an annual review in line with National Institute for Health and Care Excellence (NICE) guidance.
The areas where the provider should make improvements are:
- Monitor unfilled shifts on a consistent basis to support with identifying gaps in service provision.
- Engage with Her Majesty’s Prison and Probation Service (HMPPS) to ensure the consistent supervision of medicine queues to reduce the risk of diversion.
- Ensure systems and processes monitor that identified actions are implemented following clinical audit.
- Ensure staff receive supervision in line with policy and procedures.
Our inspection team was led by a CQC health and justice inspector supported by two CQC health and justice inspectors.
How we carried out this inspection
We accessed patient clinical records during our onsite visit on 23 and 24 May 2022. We conducted searches for patients who had been identified as having specific long-term conditions, such as diabetes and epilepsy, and sampled several patient records.
Before this inspection we reviewed a range of information that we held about the service including information we had requested from the provider in support of our inspection.
During the inspection we spoke with healthcare staff, prison staff, commissioners, people who used the service, and sampled a range of records.
We also reviewed documents that included:
- Medicines missed dose report
- List of patients with an outstanding annual medication review
- Clinical incident data including those relating to medicines
- Policies and procedures relating to medicines
- Information relating to the staffing model, vacancies and recruitment
- Staff supervision and induction compliance data
- Medicines mandatory training compliance data
- Secondary health screening compliance data
- Minutes of governance and quality assurance meetings
- Minutes of medicines governance meetings
- Staff meeting minutes
- Clinic information including cancelled clinic data
- Care plan audit data
- Mental health case load data
- Monthly management check list including fridge temperatures and emergency equipment checks
- Medications administered report