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Archived: Risley Prison - IDTS

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Inspection report

Date of Inspection: 15, 16 July 2013
Date of Publication: 16 August 2013
Inspection Report published 16 August 2013 PDF

People should be given the medicines they need when they need them, and in a safe way (outcome 9)

Not met this standard

We checked that people who use this service

  • Will have their medicines at the times they need them, and in a safe way.
  • Wherever possible will have information about the medicine being prescribed made available to them or others acting on their behalf.

How this check was done

We carried out a visit on 15 July 2013 and 16 July 2013, observed how people were being cared for, talked with people who use the service and talked with staff. We reviewed information given to us by the provider and took advice from our pharmacist.

Our judgement

People were not sufficiently protected against the risks associated with medicines because the provider did not have appropriate arrangements in place to manage medicines.

Reasons for our judgement

One prisoner who used the service said: “They (staff) make sure you get your methadone”.

We looked at the way CRI dispensed and administered methadone to prisoners at HMP Risley.

We saw that on C wing methadone was dispensed using a Methasoft Treatment Management System. This is a system used for the automatic dispensing of methadone for substance misuse treatment. Methasoft is a computer-based software programme. It incorporates all of the steps required to support responsive and reliable methadone dispensing. Patients are identified using fingerprint recognition. The methadone is dispensed using an electronic pump and all legally required records are saved automatically.

We saw that for prisoners on wings D and E, methadone was stored in controlled drugs cabinets, which was dispensed directly from a bottle and measured. We observed nursing staff working together and confirming the correct dosage had been dispensed.

For other prisoners across the prison site, methadone was dispensed using the methasoft system directly into safety proof capped bottles which were labelled appropriately. We observed nursing staff working together checking the accuracy of the labelling fixed to the bottles. This meant there were systems in place to ensure medications were suitably labelled.

We saw that the majority of methadone was dispensed to prisoners on C wing, where there was a facility for prisoners to receive their medication in privacy and without interruption. The privacy and dignity of prisoners using this facility on C wing was upheld.

We saw that prisoners on D and E wings received their medication in privacy as much as it was practical to do so within the limitations of the prison environment. We saw that a number of other prisoners received their medication at their cell door on various wings across the prison.

In all instances we saw staff correctly observing patients taking their medication as in line with CRI’s policy on supervised consumption. However we had concerns about the way staff completed medication administration records.

We observed that nursing staff on C wing completed medication administration records before a prisoner had taken their methadone. We discussed this with nursing staff on the day who acknowledged that they should only complete the record once the prisoner had consumed the medication.

We were concerned to see that one person was not on the wing when nursing staff arrived with their methadone. We saw that this methadone was returned and placed in the controlled drugs cabinet on C wing. We had a discussion with staff and the registered manager about this as nursing staff had already signed medication records to say the prisoner had received the medication, when in fact it had not been administered. This meant that there was a risk that if this medication went missing, was lost or mislaid a clear and precise audit of what had happened to the medication could not be provided. It also meant people were at risk of not receiving their medication as prescribed as records indicated the person had already received their medication when they had not.

We looked at medication records for prisoners that were not resident on C wing and found gaps in the completion of the records. When a controlled drug is administered two staff signatures were required to confirm the dose that had been administered. We observed a number of gaps in the records over a three month period. Nursing staff and the registered manager were unable to explain these gaps; they were unable to explain why signatures were missing. We were told that medication administration records were not audited on a regular basis. Staff we spoke with on the day of our inspection confirmed that they were up to date with medication training. This meant that prisoners were not sufficiently protected from the unsafe administration of medicines with HMP Risley.

We had concerns about the way medication was transported across the prison si