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Inspection Summary

Overall summary & rating

Updated 28 January 2019

Summary of findings

We undertook a focused inspection on the 6 and 7 November 2018 under Section 60 of the Health and Social Care Act 2008. The purpose of the inspection was to follow up on a Requirement Notice that we issued following a previous focused inspection in October 2017 and to check that the provider was meeting the legal requirements and regulations associated with the Act. Prior to our inspection we received intelligence from a partner organisation about arrangements in respect of medicines management when prisoners were released from HMP Forest Bank or when they were transferred to another prison. We widened the inspection to include some aspects of medicines management.

Before the inspection we reviewed a range of information that we held about the service. Following the announcement of the inspection we requested a range of information from the provider, which we reviewed. During the inspection we asked the provider to share with us further information. We also spoke with healthcare staff, other healthcare partners, prison staff, commissioners and prisoners, and sampled a range of records.

We do not currently rate services provided in prisons.

At this inspection we found:

  • Prisoners with primary mental health needs could access care and treatment within an appropriate timescale
  • Prisoners with mild to moderate mental health issues had access to planned ongoing responsive treatment that met their needs including access to therapies.

The areas where the provider should make improvements are:

  • Develop a referral pathway for prisoners with a learning disability that effectively meets their needs and provides appropriate support.
  • Ensure that primary mental health prisoners are referred to and are seen at the newly established primary mental health psychiatric clinic.
  • Ensure that systems and processes effectively monitor service quality, and particularly recent service improvements. This should include, initial health screening; access to the psychiatrist.
Inspection areas


Updated 28 January 2019


Updated 28 January 2019

At our previous inspection in October 2017 we were concerned that the initial health screen did not include a learning disability assessment and the needs of people with learning disabilities may not be met. At this inspection we found that a healthcare pathway for prisoners with a learning disability had not been developed but work was in progress to improve prisoners’ experience.

Effective needs assessment, care and treatment

  • At this inspection we found that a prison-led working group was set up to look at the management of prisoners with a learning disability within the prison. The group included representatives from the prison, education and healthcare. The prison had also held a learning disabilities week in November 2017 to increase staff awareness. A final meeting of the group was held in January 2018 and a number of actions were identified which included an identified need for a referral process that combined input from the prison and healthcare.
  • The clinical lead for the primary mental health team gave assurance that prisoners with a learning disability would be supported by the primary mental health team where a need had been identified.
  • Prisoners arriving at the prison received an initial health screen, which was completed by a registered mental health nurse (RMN) from the primary mental health team. A secondary health screen was completed by registered general nurses (RGN) from the primary health care team within seven days of a prisoner’s arrival at the prison.

  • Staff used a national template when conducting initial health screens, which did not include any questions around the identification of a learning disability. Nursing staff made appropriate referrals to the GP, substance misuse service and other specialist health services as required.

  • RMNs told us that the volume of work created by conducting initial health screens impacted on their ability to deliver primary mental health support to prisoners, including direct face to face work with prisoners. RMNs told us they were anxious as they were not trained registered general nurses and were fearful of missing important clinical information. This was a concern particularly as there was no clinical oversight of the process.

  • RMNs responsible for health screening for prisoners arriving at and leaving the prison were managed by a clinical lead who had no responsibility for the screening processes. This meant that there was no clinical oversight and management of the process, which potentially put prisoners with healthcare needs at risk. We asked the head of health care to provide us with assurance that arrangements were in place which ensured the effective management and oversight healthcare’s input into the reception process.

  • The provider sent us an action plan on the 13 November 2018 detailing how they intended to improve outcomes for prisoners when they were received into the prison. The provider told us that from Monday 19 November 2018 RGNs would undertake all initial health screens on weekdays. The provider also told us that the clinical lead for primary health care would take over responsibility for the management of reception and discharge healthcare processes. We were unable to test the impact of these new arrangements.

Monitoring care and treatment

Transfer and discharge of prisoners:

  • Prior to our inspection we received intelligence regarding arrangements in respect of medicines management. In particular prisoners who were released from the prison or transferred another prison.

  • Prisoners were responsible for ordering any required medicines seven days in advance of their release from prison. They could order these by submitting a paper application or via electronic kiosks on each wing, and posters on the wings reminded them of their responsibility to order medicines. When a prisoner ordered their medicines an acknowledgment was sent to them from the pharmacy service confirming the medicines were available.
  • The pharmacy team had effective systems and processes in place that ensured that prisoners transferring to other prisons were able to continue receiving their medicines. The system had been developed in recent months.

  • When prisoners were due to be transferred to another prison, the pharmacy team asked the prison GP to write a prescription, and ordered medication from a local pharmacy to be delivered urgently. This medication was made available in reception and given to the prisoner during a pre-transfer review. Although staff told us that they often received late notice of prisoners being transferred, we saw evidence of prompt action taken by staff to ensure that prisoners had their medicines when they transferred to another prison.

  • A list of prisoners due for release was drawn up on the evening prior to their release. A discharge ledger was held in pharmacy that included details of the prisoner and their prescribed medicines. All prisoners released from the prison were reviewed by a nurse and given any pre-ordered medication to take with them. If prisoners had not ordered their medication prior to release, they were provided with advice about how to access support and obtain medicines in the in the community.

  • Despite these arrangements, during our inspection we found some prisoners were released without their prescribed medicines. RMNs told us that they often had little time to review prisoners before discharge due to the high volume of prisoners going through prison reception each day, and they were not able to review everyone who left the prison. Some prisoners left the prison without their prescribed medicines, and their surplus medicines were returned to the pharmacy to be destroyed.

  • Recording on care records in respect of prisoners who were released was inconsistent, as demonstrated by our review of records. We could not ascertain from care records if a prisoner had received their medicines upon release. Health and justice performance indicators (HJiP) data showed that the majority of prisoners did not have their medicines when they left HMP Forest Bank. The head of healthcare attributed this to poor recordings and prison regime issues.
  • We asked the head of health care to provide us with assurance that arrangements were in place to ensure that prisoners received prescribed medicines upon release and this process was managed and monitored.

  • The provider sent us an action plan on the 13 November 2018 detailing how they intended to improve outcomes for prisoners who required ongoing access to prescribed medicines when they were released from prison or transferred to another prison. The provider told us measures were in place that ensured prisoners received their medicines upon release and from the 9 November 2018 all prisoners released from HMP Forest Bank would be provided with a discharge letter which detailed any prescribed medicines they had received whilst in the prison. We were unable to test the effectiveness of these new arrangements.

  • The substance misuse team had introduced clear processes to support staff in managing discharges and transfers of prisoners receiving treatment. Substance misuse prisoners were administered any prescribed medication before being transferred or released. When prisoners transferred to another prison, the clinical team telephoned the receiving prison to provide a handover, and completed a written clinical summary which was included with the prisoner’s general paperwork.

  • When prisoners were released into the community, the clinical team sent the prisoner’s prescription to the community drug team, and followed up by telephone to check that they had attended any planned appointments.

Primary mental health services:

  • Prisoners with primary mental health needs were monitored through nurse-led triage clinics that were held three times per week and through daily emergency triage clinics, weekly follow up clinics and at the weekly single point referral meeting.

  • Single point referral meetings were held and attended by healthcare partners and operational prison staff to discuss prisoners who they had concerns about. Due to an increase in registered mental health nurses within the integrated mental team, prisoners were now being followed up more effectively and progress updates were fed back at the weekly meeting. These arrangements meant there was effective sharing of information amongst partners with a clear focus on outcomes for prisoners.
  • The clinical lead for primary mental health services monitored the service and had recently started to analyse and report on HJiP indicators for primary mental health. The data for July to September 2018 showed a continued increase in the number of referrals to the service, and a sustained increase in the number of mental health assessments completed during triage clinics. Data also showed that a low number of prisoners failed to attend appointments, and these were subsequently followed up.
  • Weekly managers meetings were held and led by the head of healthcare and were attended by all clinical leads. However, the minutes we reviewed lacked detail and did not provide assurance about service effectiveness, such as reception screening processes and medicines management.


Updated 28 January 2019


Updated 28 January 2019

At our previous inspection in October 2017 we had concerns about the length of time prisoners waited to access primary mental health services, including assessment, therapeutic interventions and planned ongoing treatment and support. At this inspection we found that prisoners were now accessing a range a therapeutic interventions in a timely manner.

Responding to and meeting people’s needs

  • Since our last inspection and following discussions with NHS England the provider had subcontracted primary mental health services to a specialist mental health provider and an integrated mental health team (IMHT) was now in place. However, Sodexo Limited remained responsible for primary mental health services within the prison.

  • The IMHT was made up of three RMNs who were employed by Sodexo Limited and one registered mental health nurse employed by the specialist mental health partner. The team had one vacancy for a RMN. The team also included two health and well-being practitioners. A counsellor and a psychological health and well-being practitioner had been appointed and were waiting to commence employment.

  • The IMHT had been in operation since February 2018. The recruitment of staff had taken much longer than first anticipated. However the appointment of a RMN and two health and wellbeing practitioners meant that prisoners had started to access therapeutic support and RMNs were now able to follow up prisoners, to provide further support where the need had been identified.
  • A psychological wellbeing practitioner had been recruited and was awaiting a start date and a counsellor had also been appointed and was due to commence employment imminently.
  • Health and wellbeing practitioners provided a range of therapies. For example, anxiety management, sleep hygiene and coping skills. Prisoners were offered up to eight sessions with a wellbeing practitioner and developed a self-management plan during the sessions. There were 14 prisoners engaged in work with practitioners and there was no one waiting to access the service. Primary mental health nurses triaged all referrals for the service. The provider shared very positive feedback with us from prisoners who had used the service. Prisoners located on the prison inpatient unit could access therapeutic services from wellbeing practitioners.

  • Prisoners with primary mental health needs still had poor access to a psychiatrist despite the provider subcontracting a weekly psychiatric session from a partner organisation. At the time of the inspection we received confirmation that a weekly psychiatric clinic, solely for prisoners with primary healthcare needs would commence on 15 November 2018. We were unable to assess the impact this would have on prisoners at the time of our inspection.
  • RMNs provided support to Assessment, Care in Custody, and Teamwork (ACCT) meetings and reviews. ACCT is a prison led care planning system used to help identify and care for prisoners at risk of suicide or self-harm. The team prioritised attendance at ACCT reviews with a nurse from the IMHT attending the first ACCT review.

Timely access to the service

  • Access to the primary mental health team had improved and prisoners who required an emergency response or had self-harmed were seen immediately.

  • Referral into mental health services was through the integrated mental health team and referrals came from several sources. These included prison staff, other health care practitioners, reception health screening, external sources including the trust’s criminal justice liaison teams, and prisoner self-referral.

  • The team provided a daily emergency triage clinic, nurse triage clinics three times a week and was now providing follow up clinics to prisoners engaged with the service. Additionally nurses were now able to refer prisoners to one of two health and well-being practitioners for therapeutic support.

  • The primary mental health team provided a service to prisoners seven days a week. Monday to Friday between 7am and 8pm and at weekends 8am–5pm on Saturday and 8am -12pm on Sunday Outside of these hours prisoners would be seen by nursing staff from the primary health care team


Updated 28 January 2019