Item 10 - Prisoner Healthcare
North Lanarkshire Council · 21 June 2023
Back to IJB Performance, Finance and Audit Committee — 21 June 2023 and its agenda
Text extracted from the council's PDF. Layout and reading order may differ from the original.
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1 REPORT Item No: 10 SUBJECT: Prisoner Healthcare TO: Performance, Finance & Audit Committee Lead Officer for Report: Maggs Thomson, Head of Head, North HSCP Author(s) of Report Jim Duffy, General Manager, Adult Health Services Unit, North HSCP DATE: 21 June 2023 1. PURPOSE OF REPORT This paper is coming to the IJB for: For approval ☐ For endorsement ☐ To note ☒ 1.2 This paper sets out an overview of the Prisoner Healthcare service within North Lanarkshire 2. ROUTE TO THE BOARD This paper has been: Prepared By: ☒ Reviewed By: ☒ Endorsed By: ☐ Prepared by J Duffy General Manager, Adult Health Services Unit, North H&SCP. Reviewed by M Thomson
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2 3. RECOMMENDATIONS 3.1 It is recommended that the IJB for Performance, Finance and Audit Committee supports; (1) The creation of a Project Board, overseeing the implementation of improvement plans relating to HIS recommendations, internal Service Review actions and MATS Standards. (2) The ongoing funding and support for the Fixed Term Senior Improvement Manager position. (3) The work associated with locally identified Milestones for the service, as noted in the Annual Delivery Plan for 2023/24 as per summary table below Table 1- Annual Delivery Plan 2023/24 Summary Summary We aim to deliver against 2022 HIS Inspection Recommendations and against all remaining actions from our internal Service Review in 2022, and to deliver MATS in Justice. We aim to end 2023/24 with plans for sustainable performance and future delivery against the changes. Q1 1. Senior Service Improvement manager in post and inducted. 2. Measurable advancement evident in the delivery of the 6 priority recommendations from the 2022 HIS inspection. 3. Advancement in the acquisition of a LES for GP services. 4. Improvement Plan in place for HIS recommendations and actions from NHSL service review, feeding into established Performance Review Processes. Q2 1. LES agreed, or advancement on contingency plan if LES unsuccessful. 2. Measurable advancement and delivery of 6 HIS priority areas. 3. Measurable advancement in NHSL service review actions. 4. New Team leader in post and Return to full shift nursing coverage (9pm). Q3 1. Host return visit/inspection by HIS and report on delivery against 6 priority recommendations including GP services. 2. Workforce Model review planned and date identified to commence work. 3. Measurable improvement in the management of LTC in the prison population under the newly created structure with nursing staff and GP services jointly leading. 4. Established Programme Board for justice related services with prison healthcare a central component in conjunction with MATS standards. Q4 1. Measurable delivery of all actions from the NHSL service review. 2. Measurable delivery and maintenance of all recommendations from HIS inspection. 3. Consultative and preparation work complete for Workforce Model review and plan in place to begin implementation.
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3 4. VARIATIONS TO DIRECTIONS? Yes ☐ No ☐ N/A ☒ 5. BACKGROUND/SUMMARY OF KEY ISSUES 5.1 Background 5.1.1 Responsibility for the provision of healthcare in prisons transferred from the Scottish Prison Service (SPS) to the NHS in November 2011 and for HMP Shotts in Lanarkshire, it is now the responsibility of the North Lanarkshire H&SCP. HMP Shotts, a 538 place, maximum security prison for convicted adult males serving a sentence of four years or longer has a healthcare team that comprises of three sub-teams teams of Primary Care team, Addictions Team and Mental Health Team. 5.1.2 It is an isolated professional working environment, and there are significant cultural challenges related to partnership working with the Scottish Prison Service (SPS). The previous permanent on-site Senior Nurse model has been replaced with a Senior Nurse and Service Manager ‘in reach’ model providing regular presence on- site and work with the Teams. 5.1.3 Over the last 24 months the healthcare team has experienced significant and sustained staff shortages across all disciplines. This has impacted on the team’s ability to provide adequate staffing and maintain a safe skill mix. This included the lack of GP cover from 1:30pm onwards. 5.1.4 Due to the apparent challenges, the Nurse Director commissioned a ‘deep dive Service Review to be undertaken. This was completed in March 2022 and an action plan was developed identifying planned improvement actions. 5.2 Her Majesty’s Inspectorate of Prisons for Scotland Inspection 5.2.1 Her Majesty’s Inspectorate of Prisons for Scotland (HMIPS) undertook an inspection of HMP Shotts from 09- 22 May 2022, supported by Healthcare Improvement Scotland (HIS) who reviewed Prisoner Healthcare under Standard 9: Prisoner Health & Wellbeing. (HIS noted that an internal Service review had taken 4. Commencement of work on plan to provide sustainability and maintenance of the delivery of HIS recommendations and Service Review actions (audit cycle, reporting mechanisms etc.). 5. Measurable improvement in service performance and compliance as agreed in performance framework/KPI process.
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4 place ahead of their inspection and commented that this had been an area of good practice). 5.2.2 Resultantly, the nurse staffing recruitment and retention issues and associated subsequent impact on patient care, resulted in a grading of ‘Poor’ for NHS Lanarkshire. Whilst the report recognised the considerable efforts made to support the healthcare needs of patients in HMP Shotts, HIS noted; Five quality indicators were rated as satisfactory, Six quality indicators were rated as generally acceptable Five quality indicators were rated as poor. 5.2.3 There were 12 examples of good practice and 22 recommendations for improvement which include 6 priority recommendations. The Inspection Report is listed in Section 8.. 5.3 Progress to Date 5.3.1. As noted in the full report, there were 22 Recommendations. The present status of progress is detailed within Table 2 and a breakdown of these recommendation are detailed within Appendix 1 – HIS Review Recommendations Update . Table 2. Current Position on HIS Recommendations Criteria No of Recommendations Current Position on Open Recommendations RED AMBER GREEN Total Recommendations 22 0 Open Recommendations 16 0 13 3 Closed/Complete Recommendations 6 0 6 5.4 Service Review Model 5.4.1 The Internal NHSL Service Review produced an action plan with 32 Actions. The present status of progress of these actions are detailed within Table 3 and a further breakdown of these actions are detailed within Appendix 2 -Service Model Review Update. Table 3. Current Position on Service Review Actions Criteria No of Actions Current Position on ‘Live’ actions RED AMBER GREEN Total Actions 32 0 Open/Ongoing Actions 10 0 4 6
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5 Closed/Complete Actions 22 0 22 5.4.2 The implementation of the HIS recommendations and the actions from the Service Review has been formally supported by North Lanarkshire H&SCP with fixed-term funding for a Senior Improvement Manager, who will oversee and co- ordinate Improvement work to ensure the delivery of all Recommendations and Actions. 5.4.3 Additionally, it is planned that the work required in conjunction with associated work (specifically MATS in Justice) will be managed under the oversight of a Programme Board. 5.4.4 The Senior Service Improvement manager is now in post and is currently developing an amalgamated Implementation and Improvement plan which will be presented at the initial meeting of the Programme Board in June 2023. 5.4.5 Work is ongoing on staff recruitment and retention with a continued plan for Recruitment events, an application for a Secure Environment Allowance to S.T.A.C. and a current piece of work to create a Local Enhanced Service for the provision of GP cover, with one interested practice currently engaging in fact-finding and observation/participation in GP work as a way of assessing compatibility. 6. CONCLUSIONS 6.1 The management of Service Improvement and MATS standards is essential, and it is imperative that the improvement agenda is supported and implemented. 6.2 In order to meet the healthcare needs of prisoner patients, it is essential that the detailed recommendations and actions, including an improved workforce model are implemented. 6.3 The continued endorsement of and support for the incumbent Senior Service Improvement Manager post (Fixed Term for 18 months) is central to success in delivery. 6.4 achievement of our key Q1-Q4 Milestones in the Annual Delivery plan is essential to evidence the required improvement.
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6 7. IMPLICATIONS 7.1 NATIONAL OUTCOMES Link(s) to National Health & Wellbeing Outcomes People are able to look after and improve their own health and wellbeing and live in good health for longer ☒ People, including those with disabilities or long-term conditions, or who are frail, are able to live, as far as reasonable practicable, independently and at home or in a homely setting in their community ☒ People who use Health and Social Care Services have positive experiences of those services, and have dignity respected ☒ Health and Social Care Services are centred on helping to maintain or improve the quality of life of people who use those services ☒ Health and Social Care Services contribute to reducing health inequalities ☒ People who use Health and Social Care Services are safe from harm ☒ People who work in Health and Social Care Services feel engaged with the work they do and are supported to continuously improve the information, support, care and treatment they provide ☒ Resources are used effectively and efficiently in the provision of Health and Social Care Services ☒ 7.2 ASSOCIATED MEASURE(S) HIS Standard 9: Prisoner Health & Wellbeing. The identified actions and service and quality requirements as noted in the internal Service Review. Compliance with MATS Standards Generic management standards and performance requirements (including Financial balance and staff governance measures). 7.3 FINANCIAL 7.3.1 The Summary finance position for Prisoner Healthcare to the end of reporting year 2022/23 (and subsequently updated to present for the purposes of this report) is illustrated below. (Full detailed accounts are available). 7.3.2 There was an overspend mainly in non-pay which was largely characterised by the costs associated with the supply of medicines which when isolated as a cost on its own experienced an overspend of circa £170k in 2022/23. The supply of Buvidal is a significant contributory cost within this. Table 4- Summary Financial Position Nhsl Prisoner Healthcare Month 12 2022/2023 Report Refreshed On 18- May-23
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7 Annual Budget YTD Budget YTD Actuals YTD Variance Period Budget Period Actuals Period Variance Pay 1,347,509 1,347,509 1,325,641 21,868 107,431 120,768 (13,337) Non Pay 436,188 436,188 582,202 (146,014) 36,349 212,103 (175,754) Nhsl Prisoner Healthcare Total 1,783,697 1,783,697 1,907,844 (124,147) 143,780 332,871 (189,091) Staffing cost variances due to staffbank and agency nurse cover were largely tempered by the high nursing vacancy factor, as recruitment and retention of nursing staff continues to be a challenge. Pays therefore show as an underspend for 2022/23. 7.3.3 This paper has been reviewed by Finance: Yes ☒ No ☐ N/A ☐ 7.4 RISK ASSESSMENT/RISK MANAGEMENT Relevant Risk Register Details Current Risk Level Risk Owner 1. Healthcare Provision for HM Prison Shotts: Recruitment & Retention issues mean that we are unable to provide cover between 18.00 and 21.00 hrs. A safe alternative is in place until staffing levels improve. High J Duffy Relevant Risk Register Details Current Risk Level Risk Owner 2. Illicit substance misuse in prisoner group resulting in Ambulance conveyance to ED and admission to acute hospital. Low J Duffy Relevant Risk Register Details Current Risk Level Risk Owner 3. Nurse Staffing levels at HM Prison Medium J Duffy
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8 Shotts: Turnover and vacancy factor is high and this has resulted in costs for Staffbank and agency nurse cover. Actions and mitigation in place to address this issue. 7.5 ENGAGEMENT & PARTICPATION Please tick the engagement and participation objectives that link(s) with this piece of work and provide further details regarding the engagement and participation that was undertaken. Objectives Further Details ☒ Involve stakeholders in the development work aimed at achieving the national outcomes A programme Board is being established for prisoner healthcare and MATS standards. Multiple stakeholders will be included. Discussion is ongoing on how best to incorporate prisoner/family inclusion. ☒ Provide stakeholders with information on how to get involved Information on engagement will emerge form Programme Board actions □ Ensure a diverse range of engagement and participation and opportunities are in place to suit different needs Not yet in place but to be developed at and Overseen by Programme Board □ Measure how well we involve community stakeholders in the planning, design and delivery of our services Not yet in place but to be developed at and Overseen by Programme Board □ Provide regular feedback on how stakeholder engagement and participation is shaping and influencing service development and delivery Not yet in place but to be developed at and Overseen by Programme Board □ Provide support to enable stakeholder representatives to participate meaningfully and confidently at meetings Not yet in place but to be developed at and Overseen by Programme Board □ Develop participation guidelines to ensure a common understanding and set of expectations for both stakeholders and partnership staff Not yet in place but to be developed at and Overseen by Programme Board □ Support engagement planning and participation in localities, taking account of Not yet in place but to be developed at and Overseen by Programme Board
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9 7.6 INEQUALITIES & FAIRER SCOTLAND DUTY EQIA Completed & Fairer Scotland Impact Assessment Form Completed and attached to report: Yes ☐ No ☒ N/A ☐ EQIA added to website: Yes / Date added ☐ No ☐ N/A ☒ 8. BACKGROUND PAPERS Paper 1 HMIPS-HMP Shotts Report on Full Inspection 9. APPENDICES Appendix 1- HIS Review Recommendations Updated 17th May 2023 Appendix 2- Service Model Review Update 17th May 2023 CHIEF ACCOUNTABLE OFFICER (or Depute) Members seeking further information about any aspect of this report, please contact the following; Maggs Thomson, maggs.thomson@lanarkshire.scot.nhs.uk other engagement activity and local plans across the Community Planning Partnership
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11 Direction from North Lanarkshire Integration Joint Board (IJB) 1 Reference Number 2 Report Title 3 Date direction issued by IJB 4 Date from which direction takes effect 5 Direction to: 6 Does this direction supersede, revise or revoke a previous direction – if yes, include reference number(s) 7 Functions covered by direction 8 Full text of direction 9 Budget allocated by Integration Joint Board to carry out direction 10 Performance Management / Governance arrangements 11 Date direction will be reviewed
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Paper 1 Report on HMP Shotts Full Inspection 9-20 May 2022
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CONTENTS Introduction and Background Key Facts Overview by HM Chief Inspector of Prisons for Scotland Human Rights Based Approach Overview Summary of Inspection Findings Standards, Commentary and Quality Indicators Standard 1 Lawful and Transparent Custody Standard 2 Decency Standard 3 Personal Safety Standard 4 Effective, Courteous and Humane Exercise of Authority Standard 5 Respect, Autonomy and Protection Against Mistreatment Standard 6 Purposeful Activity Standard 7 Transitions from Custody to Life in the Community Standard 8 Organisational Effectiveness Standard 9 Health and Wellbeing ANNEXES Annex A Summary of Recommendations Annex B Summary of Good Practice Annex C Summary of Ratings Annex D Prison Population Profile on Annex E Inspection Team Annex F Acronyms used in this Report EVIDENCE REPORT The full inspection findings and overall rating for each of the quality indicators.
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1 INTRODUCTION AND BACKGROUND This report is part of the programme of inspections of prisons carried out by Her Majesty’s Inspectorate of Prisons for Scotland (HMIPS). These inspections contribute to the UK’s response to its international obligations under the Optional Protocol to the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT). OPCAT requires that all places of detention are visited regularly by independent bodies known as the National Preventive Mechanism (NPM); which monitor the treatment of and conditions for detention. HMIPS is one of 21 bodies making up the NPM in the UK. Her Majesty’s Chief Inspector of Prisons for Scotland (HMCIPS) assesses the treatment and care of prisoners across the Scottish Prison Service (SPS) estate against a pre-defined set of Standards. These Standards are set out in the document ‘Standards for Inspecting and Monitoring Prisons in Scotland’, published in May 2018 which can be found at https://www.prisonsinspectoratescotland.gov.uk/standards. The Standards reflect a rights based approach to an independent inspection of prisons in Scotland and are also designed to provide information to prisoners, prison staff and the wider community on the main areas that are examined during the course of an inspection. Our report provide assurance to Ministers and the public that inspections are conducted in line with a framework that is consistent and that assessments are made against appropriate criteria. While the basis for these Standards is rooted in International Human Rights treaties, conventions and in Prison Rules, they are the Standards of HMIPS. This report and the separate ‘Evidence Report’ are set out to reflect the performance against these standards and quality indicators. HMIPS assimilates information resulting in evidence-based findings utilising a number of different techniques. These include: Asking the Governor or Director in Charge for a self-evaluation – summary of their progress against previous recommendations, the challenges they face and the successes they have achieved. Obtaining information and documents from the SPS and the prison inspected. Shadowing and observing SPS and other specialist staff as they perform their duties within the prison. Interviewing prisoners and staff on a one-to-one basis. Conducting a pre-inspection health and wellbeing survey of prisoners, and focus groups with both prisoners and staff. Observing the range of services delivered within the prison at the point of delivery. Inspecting a wide range of facilities impacting on both prisoners and staff. Attending and observing relevant meetings impacting on both the management of the prison and the future of the prisoners such as Case Conferences. Reviewing policies, procedures and performance reports produced both locally and by SPS Headquarters (SPS HQ) specialists.
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2 HMIPS is supported in our work by inspectors from Healthcare Improvement Scotland (HIS), Education Scotland, Scottish Human Rights Commission, the Care Inspectorate, where appropriate the Children and Young People’s Commissioner for Scotland, and guest inspectors from the SPS. The information gathered facilitates the compilation of a complete analysis of the prison against the standards used. This ensures that assessments are fair, balanced and accurate. In relation to each standard and quality indicator, inspectors record their evaluation in two forms: 1. A colour coded assessment marker (APS TO INSERT) 2. A written record of the evidence gathered is produced by the inspector allocated each individual standard. It is important to recognise that although standards are assigned to inspectors within the team, all inspectors have the opportunity to comment on all findings at a deliberation session prior to final assessments being reached. This emphasises the fairness aspect of the process ensuring an unbiased decision is reached prior to completion of the final report. This report provides a summary of the inspection findings and an overall rating against each of the nine standards. The full inspection findings and overall rating for each of the quality indicators can be found in the ‘Evidence Report’ that will sit alongside this report on our website.
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3 Key Facts Location HM Shotts is situated in the countryside, south of the M8 motorway near the Lanarkshire village of Shotts. Role HMP Shotts is a maximum security prison for long-term adult male prisoners. It also houses a national facility within its boundaries, the National Integration Centre (NIC), which holds adult male prisoners who are in the initial stages of sentences of 8 years or over and prepares them for the eventual movement to mainstream establishments Accommodation There are two main residential units; Lamont Hall and Allanton Hall. There is also a 14 cell Separation and Reintegration Unit (SRU). All accommodation is designed for single occupancy and each cell has an integrated toilet and shower. Design capacity The design capacity is 538. Date of last inspection: 21 August – 1 September 2017 Healthcare provider: NHS Lanarkshire Learning provider: Fife college
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4 Overview by HMCIPS The Vision for Justice in Scotland 2022 aims to have effective, modern person-centred and trauma-informed approaches to justice in which everyone can have trust. Her Majesty’s Prison (HMP) Shotts was completely rebuilt in 2012 and has been well designed, with single cell accommodation for 553 and facilities fit for its purpose of holding long term adult male offenders. The prison was still in good physical order. The prison seeks to provide a secure, safe, caring and productive environment, while providing opportunities for offenders to come to terms with their sentences and address their offending behaviour. HMP Shotts was the first full inspection where HMIPS’ health and wellbeing survey was completed prior to the inspection; this provided valuable information to guide the focus of the inspection. Like the rest of the SPS, HMP Shotts has faced significant challenges over the last few years from the global pandemic. Staff shortages were evident across the establishment with healthcare delivery, access to employment, staff training, staff and prisoner engagement and evening activities detrimentally impacted. This was compounded by a period of significant incidents prior to the inspection, mostly substance related, that had affected the confidence of the prison. The national introduction of photocopying of prisoner mail, however, has led to a clear and welcome reduction in drug related incidents, and prisoners also reported they felt safer. This report identifies a number of areas of good performance which are worth celebrating, and which I hope will be taken up by other prisons in Scotland; for example good use of multi-disciplinary approaches to substance misuse, health promotion, and assisting with induction and adjustment to prison. We also saw good use being made of the Prisoner Information Channel. Most significantly, however, HMP Shotts is the first public sector prison in Scotland to install a digital ‘kiosk’ system. Used in many other jurisdictions, the positive benefits are clear; the system enables prisoners to exercise control and independence (and reduces paperwork for staff) by electronically choosing their meals, booking their own visits, buying canteen goods and checking their spend balance. HMIPS welcomes this initiative and looks forward to seeing this innovation extended into the cellular accommodation and rolled out across the estate. HMP Shotts houses the National Integration Centre (NIC) which holds approximately 60 adult male offenders who are in the initial stages of a long or life sentence and prepares them for eventual movement to mainstream prisons. We saw clear evidence of constructive relationships between staff and prisoners, resulting in suitably designed activities for each prisoner. As in the 2017 report, it was encouraging to see the operation of a Personal Officer scheme at its best.
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5 The staff who worked in the SRU demonstrated a high level of commitment and skill in working with often troubled and sometimes challenging prisoners. Good team working was evident, with investment in relationships producing positive results. Across the prison the Integrated Case Management (ICM) system was well established with a clear focus on identifying and meeting the needs of individual prisoners. Staff responsible for the operation of ICMs made effective arrangements to promote the involvement of all prisoners and, where appropriate, family members. Despite staffing constraints, HMP Shotts are to be commended for increasing the offending behaviour programme delivery during COVID-19 and for the resumption of Education and chaplaincy activities. We would nevertheless now strongly urge the early resumption of a return to a full regime. The report also highlights other areas where improvements can be made. Unfortunately, the significant and sustained pressures on healthcare staff and the detrimental impact on patient care resulted in a grading of ‘Poor ‘for NHS Lanarkshire but we nevertheless recognise the considerable efforts made in difficult circumstances by staff within HMP Shotts and the North Lanarkshire Health and Social Care Partnership (HSCP) to support the healthcare needs of patients in HMP Shotts. Despite the well-established ICM process, the waiting list for prisoners to progress to the National Top End (NTE) meant prisoners were delayed in progressing through their sentence. This problem is not exclusive to HMP Shotts and must be addressed by the SPS. Echoing the 2017 inspection report, we were concerned that long term prisoners were released back into the community from HMP Shotts without any formal opportunity to develop key life skills as part of preparation for release during their sentence. Prisoners due for release from the prison after many years also reported that they lacked confidence about important parts of their integration plans, especially housing options and access to mental health support. We were impressed by the responsiveness of HMP Shotts management team to issues raised during the inspection, which provides hope for early successes in returning to a full regime, staff and prisoner engagement, re-energising the equality and diversity (E&D) agenda, and the development of a pre-release life skills opportunity. We were concerned, however, that the Senior Management Team (SMT) and a number of management posts below that had been occupied on a temporary promotion basis for over two years; this was not conducive to stability and longer term planning so we urge the SPS to secure some more permanent arrangements as soon as possible. We were also aware that there had been tensions prior to our inspection between the trade union side and the SMT, which had been de-stabilising; it was encouraging to hear both sides say relationships were improving and we welcome continued engagement towards shared goals.
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6 We made 65 recommendations in total, but we would encourage a focus by the SPS on firstly stabilising a permanent management team structure and on the following key recommendations: Recommendation 14: The Violence Reduction Group should meet more regularly to review violence reduction and ensure actions are taken, and the Violent Incident Review (VIR) form submitted to Intelligence Management Unit (IMU) following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document Recommendation 15: SPS Anti-bullying Strategy ‘Think Twice’ requires to be re- launched to overcome the identified deficits e.g. only 40% of the staff are trained. Posters should be replenished across the establishment and a re-audit of incidents should take place to ensure all incidents of bullying, intimidation or harassment are investigated and taken seriously Recommendation 21: HMP Shotts should increase the C&R competency of staff to the accepted level as a priority. Recommendation 22: HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation. Recommendation 33: SPS HQ should review the policy for implementing a national waiting list for access to programmes and its capacity for delivering programmes against demand to ensure there is no detrimental effect on the care of individuals in custody or their ability to progress. Recommendation 35: HMP Shotts should continue to support ICM staff to address the backlog and bring all case conferences up to date. Recommendation 41: HMP Shotts should prioritise re-energising the E&D agenda, including regular meetings of the E&D committee with prisoner representation, development of an E&D action plan, more systematic monitoring of data to avoid unintentional bias with employment, education and discipline, etc., and provide comprehensive training for the E&D Manager. Recommendation 44: North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (i) ensure the risk to patients is reduced. (ii) support nursing staff in dealing with emergency situations.
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7 Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff. Finally, we would like to thank all the staff, partners and prisoners in HMP Shotts for their time and commitment to the inspection.
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8 Human Rights Based Approach Overview HMIPS is a Human Rights organisation. As such, we ground all of our inspections in Human Rights principles. Our standards are written with the international human rights framework in mind, and our inspectors apply these standards through a human rights based approach. The human rights-based overview of the inspection of HMP Shotts follows the PANEL headings, illustrating how human rights are applied to the inspection as a whole. This overview is not exhaustive of all human rights observed and engaged, but is intended as a brief synopsis of the implementation of a human rights-based approach in HMP Shotts. HMIPS’ human rights-based approach to inspection is a critical element of ensuring both that the human dignity of the prisoner is upheld and that prisons are places of productive, positive and useful education, work and interaction, leading to better outcomes in reducing recidivism and keeping our communities safer. Overview While there may not have been sufficient human rights language built into policies and actions at HMP Shotts, it was clear that the establishment respected basic principles of human rights in their day-to-day outcomes. This was pleasing to observe. As we will go onto report, the establishment did not have adequate human rights based infrastructure built into their procedures. Prisoners were not routinely consulted on matters that affected their lives and there were only very early signs of a participatory model returning to HMP Shotts, post COVID-19. The Governor and Dep. Governor exhibited a strong grip of human rights principles, dealing with human rights and equality matters in an appropriate, swift and effective manner when they reached them. Due to a mix of high staff turnover, capacity issues and the pandemic, this approach had unfortunately not trickled down to middle and front line managers who demonstrated gaps of experience and competency of these matters. This was no fault of the personnel in question, but a reflection of the need of the establishment to run up to date and robust training to all staff, and HMIPS would encourage the SPS and HMP Shotts to do so. The SPS have a positive obligation under article 2 of the ECHR right to life, and the CPT statement of principles reinforced that in the context of COVID-19 “The basic principle must be to take all possible action to protect the health and safety of all persons deprived of their liberty. Taking such action also contributes to preserving the health and safety of staff.” HMIPS do not underestimate the strain COVID-19 placed on establishments. It was right and proper that protecting the health and safety of both prisoners and staff took priority over certain functions of prison management. We now expect prisons to put in place mechanisms to restore regime, meaningful activity and engagement at pace. Too often during the course of this inspection, inspectors were told that activities had
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9 been paused due to the pandemic, without the accompanying rationale, risk assessments or mitigations we would expect. As we will go on to report, prisoners need to be consulted, feel empowered and have meaningful say over their lives. With cancelling of Prisoner Information and Action Committees (PIACs), for example, this minimised the opportunity for this to occur. To the establishment’s credit, it seemed various activities we would expect were beginning to be reinvigorated, but this was not happening at the sort of pace inspectors would like to see. Overall, HMP Shotts was an establishment that respected the basic foundations of a human rights approach in their outcomes. HMIPS would encourage the establishment to go further, embedding the culture within staff of all levels, and establishing a firmer grip of human rights and equality throughout their processes. PANEL Participation “Prisoners should be meaningfully involved in decisions that affect their lives” Despite a background of a good participatory model in the past, which HMIPS have previously been pleased to report – disappointingly, at the time of inspection HMP Shotts demonstrated neither consistent nor robust examples of prisoner participation. PIACs can be a good opportunity to meaningfully involve prisoners in decisions that affect the prison. Unfortunately, these were not utilised at HMP Shotts. While there was a plan to re-establish a PIAC model, they had been suspended throughout the pandemic which significantly hampered prisoner’s ability to feel that their voice mattered. It was also noted by inspectors that the National Induction Presentation did not cover PIACs, which meant a key vehicle for prisoners to be represented was not being brought to the attention of newly arriving individuals. While staff and prisoner relationships were good, it was clear to inspectors that prisoners in general did not feel that their opinions, views and thoughts were a priority to staff in decision making. HMIPS encourages HMP Shotts to develop their PIAC model further. While it does not involve cumbersome work, a good PIAC model can greatly influence the participatory success of an establishment and help make prisoners feel heard and engaged. If the establishment had concluded that a formal PIAC model was unachievable due to the pandemic, HMIPS would have hoped to see more informal, yet meaningful, attempts at consultation by staff to mitigate this. We saw no such evidence. The only exception to this was the good practice demonstrated by the library team who actively sought feedback on the library stock, rules, service and environment. The library assistant engaged prisoners who attended the library, and importantly, those who didn’t by seeking feedback on the halls. She displayed the feedback quarterly and reported back to all service users what had been changed as a result of opinions and views gathered. Inspectors were impressed by this approach and it
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10 represented very good practice indeed. HMIPS would encourage HMP Shotts to take elements of this practice and incorporate it throughout the prison. Inspectors marked the E&D provision of the establishment as poor in QI 8.1. This was for three main reasons: 1) The E&D Committee had been suspended for a prolonged period of time and had only just begun to be reinvigorated. E&D concerns do not cease due to the pandemic and it is incumbent on the establishment to actively ensure those with protected characteristics and the most vulnerable are not being disproportionately affected by prison rules, especially during a pandemic. Inspectors were not satisfied that HMP Shotts demonstrated they had the appropriate mechanisms in place to assess if this was occurring. 2) There was a lack of awareness and competency amongst staff of their obligations concerning E&D, including members of the E&D Committee. The Committee were well intentioned, but did not have sufficient training to perform their role. The E&D Manager was being supported by a member of the SMT, but disappointingly had received no training in E&D matters. It is important that prison staff receive E&D training on how to respect the rights and meet the specific needs of detainees in situations of vulnerability, and the skills necessary for working with them. Rule 75 of the Mandela Rules is clear that the prison administration has to ensure the continuous provision of in-service training courses with a view to maintaining and improving the knowledge and professional capacity of its personnel, after entering on duty and during their career. 3) There was no local action plan, strategy or policy. What intentions the Committee were able to provide did not include focussing on systemic issues vulnerable individuals may be experiencing and were instead more focussed on awareness raising. HMIPS would expect to see a combination of both approaches in the Committee’s plans. There had also been no outreach to prisoners to have a prisoner representative on the E&D Committee. This is a key part of ensuring minority groups within an establishment are represented. Although inspectors were told this was in process and would hopefully be occurring shortly. Inspectors found a lack of awareness among prisoners of available processes where they could influence decision-making. In general, it was clear to inspectors that participation had not been a priority for the prison in recent times. There were very early signs of a participatory model returning to HMP Shotts, but this must be developed further to embed a culture and meaningful involvement of prisoners in decision making. Components to the principle of participation include that it must be active, free and meaningful and give attention to issues of accessibility, including access to information in a form and a language that can be understood. HMIPS would expect that any barriers to participation are identified and that those prisoners would be assisted to overcome them in order to meaningfully participate.
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11 Accountability “There should be monitoring of how prisoner’s rights are being affected as well as remedies when things go wrong” There was a framework of administrative accountability in the prison. However, effective accountability based on human rights standards were not consistent at the time of the inspection. This is not to say that human rights were readily ignored; however reference to standards, rules and human rights-based criteria were minimal. HMIPS found prisoners had little faith in the complaints system and a low level of confidence. On review of PCF1 and PCF2 complaints, inspectors found responses to be timely, robust and appropriate. In particular, PCF2 responses were worthy of mention, the Governor took time to investigate matters diligently and provided full responses to those submitting complaints. The Governor (or Deputy Governor) would frequently meet with prisoners who had submitted PCF2 complaints to discuss their concerns and follow up with a written note. HMIPS were pleased to see the senior management of HMP Shotts took complaints seriously and dealt with them robustly. That said, the establishment should take more steps to recognise the disconnect between prisoners and the complaints system. Prisoners need to be assured that their voice is listened to and that authorities are accountable when things go wrong. Despite the process appearing robust when complaints were received, more effort should be taken to provide prisoners with confidence in the process. More widely, HMIPS have concerns about the extent to which the SPS complaints matches the best practice model articulated by the Scottish Public Services Ombudsman, but HMP Shotts implemented the current system effectively. However, in line with our remarks above around the E&D processes at HMP Shotts, inspectors did have concerns around the use of equality and diversity form (EDF) complaints. An EDF acts as an addendum to a PCF complaint where the complainer believed the issue to concern an E&D matter. Where such a form was attached, the complaint was sent to the E&D manager to investigate and reported back separately. These complaints should be reviewed by the E&D Committee to identify systemic issues that may be going wrong and address them prison-wide. While not unique to HMP Shotts, inspectors found this process to be lacking. The process of dealing with an EDF complaint did not differ in any clear way, in either process or outcome, from a standard PCF complaint – rendering it without value. HMIPS would strongly encourage SPS HQ to re-examine processes and procedures in place around E&D complaints. Internal audits from the establishment were mixed, but mostly positive. Compliance processes appeared to be highly efficient and well managed. The establishment had taken decisive action to address the areas of poor performance identified in the previous HMIPS inspection report. Of some concern was the PRL audit around E&D which suggested a 100% compliance rate. This was not in line with inspector’s findings and we would suggest HMP Shotts review their internal reporting.
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12 NON-DISCRIMINATION “All forms of discrimination must be prohibited, prevented and eliminated. The needs of prisoners who face the biggest barriers to realising their rights should be prioritised.” Non-Discrimination requires the duty bearer to go further than not actively discriminating – it is not a passive duty but an active one, to make deliberate efforts to prevent discrimination from occurring in all forms. In this regard, inspectors saw positive examples from HMP Shotts in almost all of our standards. Induction material was provided in a number of different languages and the establishment had a good procedure in place for use of translation services where necessary. The induction officer and the librarian had a good working relationship where she would advise the library of any arriving prisoners who spoke a foreign language, allowing the library to source material which the prisoner could access. The library in general had a good selection of foreign language books, although it was disappointing to hear that the main supplier of foreign books to the library had recently gone out of business. The library was actively seeking a new supplier and it is hoped this can be achieved without delay. Foreign national prisoners reported feeling safe and having their basic needs met. A personal emergency evacuation plan (PEEP) list was provided and the requirements of individuals spoken to confirmed they should be on the list. Officers demonstrated good knowledge of the individuals and the background behind their requirements. Accessible cells were of a good standard and met the needs of those occupying them. In general, prisoners were supported to practice their religion and afforded the appropriate faith based meal by the Kitchen. Inspectors were informed that HMP Shotts had previously had a policy whereby Jewish prisoners requesting a Kosher meal were required to prove their religious heritage to be eligible for a Kosher meal. This was poor practice, and HMIPS are pleased to hear it has been overturned by the current prison administration. Inspectors were informed of an occasion where the previous policy had mistakenly been applied by a member of staff, and we would encourage the establishment to ensure all staff are up to date with policy to ensure this is not repeated. The chaplaincy was excellent and, despite staffing issues, were supporting prisoners of all faiths and none. Access to “enhanced work parties” which paid slightly more and were for low risk prisoners was not equal for protection and non-protection prisoners. HMIPS recognise the difficulty in allocating work in a large prison with a varied population, but we encourage the establishment to try to afford equitable access across the population.
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13 Empowerment “Everyone should understand their rights, and be fully supported to take part in developing policy and practices which affect their lives” Much of the discussion above around participation and accountability also applies to empowerment – prisoners cannot be empowered if they do not have opportunities to participate or do not have recourse to hold authority to account. We would expect prisoners to understand their rights and be fully supported in utilising them. Inspectors were pleased to note that prisoners could easily request maintenance issues to be logged, mattresses replaced or their cell to be painted. This level of empowerment over their own environment was pleasing to observe. Information provision was adequate, with copies of the prison rules, SOPs, and legislation available on request. This could be improved by having the material in easy reach of prisoners without having to request it. It is also important from an empowerment perspective for prisoners to know what sort of legal texts are available to them, while it is reassuring that the prison make the material available to prisoners, this should be signposted better. HMIPS found discipline hearings and case conferences supported prisoners well, allowing them to understand the actions taken against them. There was time taken to explain decisions and the actions prisoners could take if dissatisfied with any outcomes. Inspectors found that generally prisoners understood why they were being managed in a certain way, and what was expected of them to turn their situations around, particular when being managed under rule 95. HMP Shotts piloted a Kiosk system which allowed prisoners to use a computer system in their hall to access important material, make meal choices and other functionality. Once this system is fully exploited, this will be a good example of empowerment. The establishment must be careful to ensure individuals of all technical and literacy ability are supported to use the system, but in general HMIPS are very supportive of its incorporation and extension. HMIPS would like to see prisoners at the centre of policy and decision making, with more engagement and involvement at all levels. LEGALITY “Approaches should be grounded in the legal rights that are set out in domestic and international laws” A human rights-based approach requires the recognition of rights as legally enforceable entitlements and is linked to national and international human rights law. The UK must respect the UN Standard Minimum Rules for the Treatment of Prisoners (Nelson Mandela Rules); the European Prison Rules; The Convention against Torture, including the Optional Protocol and others. It is important that all categories of prisoners enjoy the full range of human rights and that staff are
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14 adequately supported. Inspectors have identified areas where they believe further action is required, in particular to ensure that more marginalised prisoners do not fall through the gap. The realisation of human rights is facilitated in practice by both the provision of information and the need for proactive action to be taken to ensure prisoners are accessing their rights in practice. A human rights-based framework is concerned with anticipating areas of prison life where problems are likely to arise, responding to prisoners needs as they are raised and building in monitoring mechanisms to ensure systems are improved through experience. This is the sort of human rights infrastructure which could be further developed at HMP Shotts. Inspectors did not find practice which directly called into question the legality of the establishment, but we do encourage HMP Shotts to work harder to actively apply a human rights based approach in their activities.
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15 STANDARDS, COMMENTARY AND QUALITY INDICATORS STANDARD 1 - LAWFUL AND TRANSPARENT CUSTODY The prison complies with administrative and procedural requirements of the law, ensuring that all prisoners are legally detained and provides each prisoner with information required to adapt to prison life. The prison ensures that all prisoners are lawfully detained. Each prisoner’s time in custody is accurately calculated; they are properly classified, allocated and accommodated appropriately. Information is provided to all prisoners regarding various aspects of the prison regime, their rights and their entitlements. The release process is carried out appropriately and positively to assist prisoners in their transition back into the community. Inspection Findings Overall Rating: Satisfactory performance In this standard, one quality indicator was not applicable, seven were rated as satisfactory performance and one was generally acceptable giving an overall rating of satisfactory performance. There was one example of good practice and two recommendations for improvement. HMP Shotts was a long-term establishment that did not receive prisoners directly from court, only transfers from other establishments. Therefore, new arrival numbers were low and every prisoner had spent time in another establishment prior to arriving. For this reason, prisoners already knew their release dates and had a good understanding of how prisons in Scotland run. The prison also had the benefit of knowing who was arriving and when, which allowed them to classify prisoners in advance and agree their location within the prison. If a prisoner attended court whilst in custody and the outcome affected their release dates, there were efficient processes in place to inform prisoners and interested parties of their new dates. Due to the low number of prisoners arriving, inspectors were only able to observe one new admission during the inspection. However, staff were able to clearly explain the processes, which were supported by Standard Operating Procedures (SOPs). A Reception Risk Assessment (RRA) and First Night Admissions Checklist were completed for every prisoner, and inspectors were content that all prisoners were assessed regarding their ability to understand and had the opportunity to engage with the admissions process. Prisoners were provided with sufficient information about HMP Shotts via the First Night in Custody Checklist and the National Induction Presentation (NIP), which was offered to all prisoners. The induction officer proactively met with every prisoner to encourage them to attend and establish their background, and then tailored it to their needs. It was delivered on a one to one basis or occasionally in small groups and was well received by prisoners. A helpful Family Information Awareness Package and face to face induction session was available to friends and family of prisoners in
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16 HMP Shotts. SPS HQ need to review the NIP and booklet to ensure that it provides up to date information to prisoners. There were good processes in place for liberating prisoners and the release process ran smoothly. The staff undertaking the admissions, induction and liberations process were friendly, polite and professional, and knowledgeable about their role. Prisoners spoken to were content that they had received the information they required. In terms of the PANEL principles for this Standard: Participation. Prisoners were invited to engage in the admissions process via the RRA form and the First Night Admission Checklist. Both of which were completed in a confidential setting. Accountability. There were efficient processes in place for admission to and liberation from HMP Shotts. During the reception process and on arrival at the hall, prisoners were provided with information about their entitlements. The Links Centre Officer met with every prisoner in advance of their induction and tailored the presentation to suit their needs. The officer also met with them in advance of their liberation to offer support and guidance appropriate to their needs e.g. benefits advice, applications for ID. Non-discrimination and equality. Prisoners were classified and allocated to an area in the prison in advance of them arriving, so they were quickly placed in the area that best suited their needs. Prisoners that required additional assistance with the admissions process were identified on arrival at reception. Translation services were available and guidance for staff on how to use them. Prisoners were offered guidance and support in advance of their liberation date. Empowerment. Prisoners were provided with an Admission Information Pack in reception and were taken through a First Night Admissions Checklist on arrival at their residential hall. There was sufficient information provided in these to enable the prisoner to know their rights in advance of attending a full induction session, which provided further valuable information. The checklist and the RRA enabled staff to identify prisoners with additional needs. All documentation was available in nine other languages, braille and British Sign language (BSL). Legality. Staff followed the lawful procedures and completed them in a professional manner. Encouraging observations The Family Information Awareness Package for families and friends of prisoners
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17 Emerging concerns SPS HQ should take action to update the NIP and booklet to ensure it provides up-to-date information to prisoners. The Link Centre Officer responsible for delivering induction was a singleton post and there was no cover during absence.
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18 Quality Indicators 1.1 Upon arrival all prisoners are assessed regarding their ability to understand and engage with the admission process. Rating: Satisfactory performance HMP Shotts did not receive prisoners directly from court, therefore the opportunity to observe the admissions process was greatly reduced. However, staff were able to walk inspectors through the process and although only observing one admission, standards were fully met. The reception area was quiet and calm due to the low number of admissions, which contributed to a relaxed experience for those arriving. If more than one prisoner arrived at reception, they were brought off the escort van one at a time and processed at the staff desk, which allowed for confidential discussions to take place. Assessing their ability to understand and offering an opportunity to engage in the admissions process was done via the RRA form. Reception staff asked many of the RRA questions whilst searching the prisoner in a private setting, which reduced the admission time and made the process more relaxed. Reception officers were friendly, polite and professional when interacting with prisoners. An RRA was also completed for those returning from court or hospital and all prisoners coming through reception saw a nurse in a private room. Foreign national prisoners were directed to the language identification charts to ascertain which language they spoke. There was a folder held with instructions on how to use translation services, but inspectors were advised that it was rarely required. There were two SOPs covering the admissions process, one of which was specifically for prisoners’ subject to or suspected to be infected with COVID-19. Inspectors observed that staff followed the instructions laid out. Inspectors were informed that admissions could be processed quite quickly dependent upon how much property came with them. Inspectors spoke to prisoners who had recently been admitted and they were all positive about the experience and the staff working in reception. Reception staff had received relevant training to carry out their role. 1.2 On admission, all prisoners are provided with information about the prison regime, routine, rules and entitlements in a form that enables the prisoner to understand. Rating: Satisfactory performance Prisoners arriving at HMP Shotts had already spent time in another establishment. Therefore, they had an understanding of how prisons run, and the core screen paperwork had already been completed and information recorded on PR2.
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19 New admissions were provided with an Admission Information Pack in reception, written by the person responsible for delivering induction. The pack provided prisoners with enough of an understanding about how HMP Shotts ran and their entitlements until they could be offered a fuller induction. The pack was available in nine different languages, BSL and braille, and staff were aware of how to use interpretation services if required. With the exception of the race relation statement, there was no information displayed on the walls of the reception or holding areas. Inspectors were informed that the TVs with an information channel and posters had been removed as they were being destroyed. HMP Shotts should consider reintroducing them to reinforce the information provided in the pack and also help prisoners pass their time in reception. There were no peer supporters working in the reception area and HMP Shotts should consider adding peer supporters in this area. On arrival at their hall of allocation, prisoners were taken through a First Night Admissions Checklist by residential staff, usually in the evening once prisoners had been locked up to allow officers sufficient time with people. Again prisoners had gone through a first night in custody process at their receiving prison, but it was helpful to provide further information relevant to HMP Shotts. They were also provided with a Health and Safety Policy and an SPS booklet. The Checklist identified communication barriers, which allowed officers to tailor their delivery to suit the person’s needs. It was signed by the prisoner and the residential officer, assured by an FLM and sent to the induction officer within 48 hours, to help form the basis of the prisoner’s induction into Shotts. There was a First Night in Custody Protocol available to staff to ensure consistency in the process. Prisoners spoken to were content that they were provided with enough of an understanding of how the prison ran during the admissions process. 1.3 Statutory procedures for identification and registration of prisoners are fully complied with. Rating: Satisfactory performance The admissions process SOPs covered the identification and registration of prisoners, and reception staff were observed to complete the process as instructed. This included checking the Prisoner Escort Record (PER) and querying any issues/concerns with escorting staff, completing the seven-point warrant check and confirming the prisoner’s identity using the warrant for reference. The PER should identify any special needs, including risk factors and the RRA provided a further opportunity for this. As reported in QI 1.1, an RRA was completed for those returning from court, which took account of any changes of circumstances and needs that may arise as a result of this.
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20 PR2 was updated as appropriate and the warrant was then passed to the Criminal Desk. See QI 1.7 for more about this process. 1.4 All prisoners are classified and this is recorded on the prisoner’s electronic record. Rating: Satisfactory performance As reported previously, HMP Shotts did not receive prisoners straight from court. They were transferred in from another establishment, which meant that the prison knew in advance who was arriving and on what date. The Population Manager at HMP Shotts managed this process, with input from the Prison Management Meeting. The Population Manager had built up good relationships with other establishments and liaised with them about transfers in and out of HMP Shotts. He had various spreadsheets in place to manage the process efficiently. He arranged for the necessary background checks to take place and allocated prisoners to a suitable location in the prison before they arrived. A weekly email was sent to interested parties on a Friday for the week ahead, detailing all transfers in and out of the establishment. PR2 was updated as appropriate. The exception to this was prisoners eligible for placement into the National Induction Centre (NIC), where the NIC manager managed transfers in and out and arranged for background checks to be completed before accepting them. 1.5 All prisoners are allocated to a prison or to a location within a prison dependent on their classification, gender, vulnerability, security risk or personal medical condition. Rating: Satisfactory performance As reported in QI 1.4, HMP Shotts were aware of prisoners due to arrive in their establishment in advance. Other establishments contacted the Population Manager at HMP Shotts with requests to transfer prisoners to them, and HMP Barlinnie issued a weekly list of long-term prisoners (LTPs) waiting to transfer to a long-term establishment. The Population Manager used a database and spreadsheet to manage this process. He arranged for the necessary checks to be completed, allocated them a location in the prison before they arrived, and informed reception staff where the prisoner should be located. If a prisoner with accessibility needs was on the list to transfer in, they would not be taken unless there was an accessible room available for them. The Population Manager could not recall this ever having been an issue.
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21 The NIC manager managed this process for those being placed in the NIC. Eligible prisoners were interviewed and must agree to participate in the NIC regime before being accepted. Prisoners who request protection were assessed prior to going on protection and were reviewed annually. 1.6 A cell sharing risk assessment is carried out prior to a prisoner’s allocation to cellular accommodation. Rating: N/A All prisoners held in HMP Shotts at the time of the inspection were placed in single cell accommodation, therefore there was no requirement for cell sharing risk assessments. 1.7 Release and conditional release eligibility dates are calculated correctly and communicated to the prisoner without delay. Rating: Satisfactory performance The staff on the Criminal Desk within HMP Shotts were responsible for the calculation of release dates, therefore all warrants were passed to them by reception. Because HMP Shotts did not receive prisoners directly from court, they did not provide those arriving with release dates as they would already know them. However, the Criminal Desk rechecked the calculation to be confident that the dates were correct for those in their care. If a prisoner attended court whilst in custody and the outcome affected their release date, reception notified the Criminal Desk and passed the warrant to them. The Criminal Desk recalculated their release dates and updated PR2 within 24 hours. There was an assurance process in place whereby the manager checked and signed off the calculation and confirmed the date on PR2. A critical dates template was then sent to the prisoner to inform them of their new dates and an email was issued to relevant staff attaching the warrant and sentence calculation. If their dates were not affected following a court appearance, the criminal desk emailed staff to inform them of any additional charges and confirmed no change to their release dates. Staff confirmed that there were good relationships in place with the Crown Office and Procurator Fiscal Service (COPFS) should they need to query anything on the warrant. To date there had been no detainee or liberations in error at HMP Shotts. There were two members of staff working on the Criminal Desk. Both were competent in warrant identification and calculation and they covered for each other during leave periods. The processes in place were efficient and there was a suitable assurance process in place. All paperwork was stored and destroyed appropriately.
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22 1.8 All prisoners attend an induction session as soon as practicable, but no later than one week after arrival, which provides a thorough explanation of how the prison operates and what the prisoners can expect, including their rights and obligations. Rating: Generally Acceptable performance HMP Shotts received a low number of new admissions, and during the pandemic this was further reduced. Prisoners arriving had already completed national induction at their previous establishment. The Links Centre Officer was responsible for delivering induction to new admissions and was clearly enthusiastic about her role. She was notified of new admissions via the First Night Admissions Checklist sent to her from residential hall. She proactively arranged to meet with every new admission to encourage them to attend induction, and to find out their background and identify any communication needs so that she could tailor the presentation to suit. It was delivered on a one to one basis or occasionally in small groups. Translation services were used for foreign nationals as required and had recently been used to communicate with a Vietnamese prisoner. The National Induction Programme (NIP) was used as the basis for the induction and text was added to provide information pertinent to HMP Shotts. Inspectors noted that the NIP did not cover (PIAC), which is an important vehicle for prisoners to have their say and influence decisions that affect their life. HMP Shotts updated their presentation during the inspection. HMIPS ask that Scottish Prison Service Headquarters (SPS HQ) update the presentation to include this. Inspectors observed delivery of the NIP to a new admission who had not been to prison before. It was very clearly delivered, in a supportive but professional style, and tailored to suit the individual. It provided a thorough explanation of how the prison operated. Prisoners spoken to were positive about the information provided to them during induction. Those that did not wish to attend induction were provided with an NIP booklet, which was available in nine other languages, braille and BSL, and non-attendance was recorded on Prison Records System (PR2). No follow-up action was taken, but inspectors were not overly concerned as they would have received induction before arriving at HMP Shotts. Inspectors noted that the induction booklet was out of date, e.g. it talked about smoking in cells which was no longer permitted and referred to Visiting Committees. SPS HQ should take action to update the booklet and reissue it to prisons. Induction was delivered as quickly as possible but not always within seven days. This was because the Links Centre Officer was a singleton post and the officer had other duties to attend to. There was also no cover when the officer was absent. Inspectors were not overly concerned about this because new admissions would have received the NIP before arriving at HMP Shotts. They were also given the Admissions Information Pack in reception and taken through the First Night Admissions Checklist on arrival at their residential hall. However, HMP Shotts should aim to deliver an induction to all new admissions within the agreed seven days.
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23 HMIPS were pleased to hear that HMP Shotts issue a Family Information Awareness Package to families and friends of prisoners, along with the offer of a face-to-face Family Induction that had been delivered in both the prison and in the community. This is considered good practice. Recommendation 1: SPS HQ should take action to update the NIP and booklet to ensure it provides up to date information to prisoners. Recommendation 2: HMP Shotts should arrange cover for the Links Centre Officer when they are absent. Good practice 1: HMP Shotts issue a Family Information Awareness Package to families and friends of prisoners. 1.9 The procedures for the release of prisoners are implemented effectively with provision for assistance and basic practical arrangements in place. Rating: Satisfactory performance Standard 7 will report on how the release process proactively facilitates the prisoners transition back into the community. For those being liberated, the Parole Board for Scotland sent the license conditions to the Criminal Desk. All paperwork was then sent to the relevant Unit Manager to sign off and they met with the prisoner one or two days in advance of their release to talk them through their license conditions and provide them with a copy. The Criminal Desk sent out a liberation list mid-way through the month for the following month, so that all relevant staff had a few weeks’ notice of prisoners due for release. Prior to release, the Links Centre Officer offered support to prisoners with benefit entitlements including community care grants, assisted them to make an application for a basic bank account and a citizen card photographic ID. She also offered advice about transport to their destination and location of GP surgeries. On their date of release, prisoners attended the prisoner reception area where they were reminded of their license conditions. All personal property and money stored on their behalf was returned to them and signed for, with the exception of their mobile phone that was returned to them at the front of house before leaving the establishment. They were offered holdalls to place their property in which provided them with privacy on release. Every effort was made to coincide their release time with transport links and appointments made in the community, and inspectors witnessed this happening. For those that required it, Naloxone was placed in their property by healthcare staff in advance of their release date. If required, prisoners being liberated were offered a travel warrant to provide them with a means to reach their destination. Stocks of appropriate clothing were held in reception should prisoners require it. Prisoners were also invited to participate in an exit interview to allow the prison to review their experience of HMP Shotts. They were then escorted to the front of house reception area where their details were checked again and they were permitted to leave the establishment.
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24 Inspectors were able to observe two liberations during the inspection, and followed them on their journey, from being brought to the prison reception area from their residential hall to being released through the front of house reception. The process ran smoothly and staff dealt with the prisoners really well, providing reassurance for those who were nervous about being released. The Criminal Desk sent a notification to interested parties, such as Police Scotland to inform them that a prisoner had been liberated and attached their licence conditions. An SOP was available to staff to cover the release process.
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25 STANDARD 2 - DECENCY The prison supplies the basic requirements of decent life to the prisoners. The prison provides to all prisoners the basic physical requirements for a decent life. All buildings, rooms, outdoor spaces and activity areas are of adequate size, well maintained, appropriately furnished, clean and hygienic. Each prisoner has a bed, bedding and suitable clothing, has good access to toilets and washing facilities, is provided with necessary toiletries and cleaning materials and is properly fed. These needs are met in ways that promote each prisoner’s sense of personal and cultural identity and self-respect. Inspection Findings Overall Rating: Generally acceptable performance In this standard, four quality indicators were rated as satisfactory, one was rated as generally acceptable and one was rated as poor, giving an overall rating of generally acceptable performance. There was one example of good practice, and eight recommendations for improvement. HMP Shotts was built in 2012 with all cells being single occupancy. The original operational capacity was 553 but was increased to assist with population issues during COVID-19. The four accessible cells were of a good size and practical construction, containing the necessary equipment and mobility aids for the occupants. The prison buildings were found to be in good condition, fit-for-purpose, and to have good levels of cleanliness. All areas had cleaning schedules and each residential area had at least one prisoner trained in dealing with biohazard incidents. Although biohazard kits were available, the contents varied in every hall and the majority of staff were not aware that an up-to-date ‘grab box’ was available for use. The standard of prisoners bedding, mattresses etc. was of an appropriate quality in most cases with the majority of prisoners having their own personal bedding. The prison laundry worked well with efficient processes in place, however It was noted a need for an improved method around the securing of laundry bags to prevent loss or damage. Prisoners were given free access to essential toiletries on the halls, with adequate items in stock. In addition, the prison canteen offered a good range of toiletries to suit all budgets. Although Inspectors were informed that there had not been a PIAC in respect of the canteen since February 2020 due to COVID-19 restrictions, they were plans in place to restart them at the end of June 2022, giving prisoners the opportunity to influence the items available for them to purchase.
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26 Prison issued clothing was held in a store room located on each residential area and found to be well stocked. HMIPS found that prisoners knew the process in respect of requesting clothing and would receive it with little or no delay. Prisoners ordered their meals through the new Kiosk system, which clearly displayed nutritional information and allergens contained in all choices. However, updates to the Kiosk were required to make the process run more smoothly. A process was in place to cater for those that required a special diet and inspectors were pleased to see a varied bespoke menu in place for one prisoner with health issues. Overall cleanliness of the pantries was good, but there was room for improvement with regards to dealing with waste food products from the previous day’s meals. Although issues around the corrosion of microwave ovens were highlighted in an internal audit in February this year, this had yet to be addressed. A significant number of prisoners (75%) expressed dissatisfaction with the overall quality of food in HMP Shotts, with most stating that it was ‘soggy’ or ‘stodgy’. Having observed the food trolleys, which were loaded and sent to the halls as close to meal time as possible, there still seems to be an issue with the quality which could be related to the type of trolley being used. We encourage HMP Shotts to review their trolleys and look at those in HMP Low Moss, where the food trolleys were found to have less detriment on the condition of food arriving at the halls. Food was not always temperature checked at the point of service and very few prisoners serving food wore the appropriate PPE. Only one area was observed securing the pantry door to prevent unwarranted access during meal service. In multiple locations some items were placed on a dining table where self-service appeared to be the norm. This was concerning for potential cross contamination as well as portion control. Training records were reviewed and showed that only 77% of prisoners working in the Catering Department had completed the required Food Hygiene certification, with only 50% of prisoners trained. In terms of the PANEL principles for this standard: Participation: PIACs in respect of the canteen had not been held since February 2020, it was encouraging to see that they were scheduled to start again in June 2022 but this was not met at the time of the inspection. Staff and prisoners were aware of how to raise maintenance issues and they were generally dealt with promptly, replacement clothing, bedding, towels and toiletries were readily available on request and in good supply. Accountability: There were a number of checks and assurances within this standard including mattresses being replaced on request and each hall being allocated three new mattresses a month with a rotational change every three years to ensure they were fit-for-purpose. A process was in place for access to the laundry by all prisoners three times a week and for the supply and replacement of clothing.
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27 There was a good maintenance and prevention programme in place through the “Agility” platform to ensure issues were prioritised and dealt with efficiently. Non-discrimination and equality: Inspectors did not witness any direct discrimination during the inspection. Empowerment: Prisoners had access to the basic requirements for a decent life and understood the process for raising maintenance issues, obtaining clothing and essential hygiene items. Prisoners were permitted to wear their own personal clothing whilst in the halls. Legality: Inspectors did not find anything during the inspection of this standard that compromised any domestic or international laws. Encouraging observations The size and layout of the accessible cells. The planned return of PIACs for the prisoner canteen process. Cleanliness and general condition of the prison. Maintenance programme had a low number of outstanding jobs and the majority were dealt with within the allocated timescales. Emerging concerns The high proportion of prisoners who complained about the food quality The solution for securing prisoners laundry bags was to tie a sock around the neck of the bag so it can be identified by the prisoner alone, this process was explained as part of the induction process and is far from professional. Numbered ties should be considered as a secure way of identifying property in the laundry. Biohazard ‘grab kits’ require to be monitored and maintained on each hall. All prisoners involved in food production or service should be appropriately trained to carry out these duties. All prisoners serving food should be wearing the appropriate PPE. All areas should be checking food temperatures and recording it appropriately. The prison should adhere to point of service processes to ensure that all food is served in conditions that comply with all Food Hygiene requirements. All equipment with signs of corrosion should be replaced. There is a need to review the delivery equipment from the Catering Department to Halls to deliver a better quality product at point of service.
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28 Quality Indicators 2.1 The prison buildings, accommodation and facilities are fit-for-purpose and maintained to an appropriate standard. Rating: Satisfactory performance The general feel around the prison was of a clean and well maintained establishment with buildings that were fit-for-purpose. There was no evidence of structural issues, graffiti or walls requiring painting or repair; the paintwork throughout the prison was fresh and well maintained. A good process was in place on each level within both halls for painting, with equipment held within each hall and paint sourced through the maintenance team. Prisoners could easily request their cell to be painted and this was facilitated by the nominated prisoner painting party within that hall. This process worked well. Inspectors looked at the four accessible cells within the prison and sought the views of three of the occupants. The cells were a good size with large glass fronted wet rooms containing all of the necessary equipment and access handles for those with mobility issues to comfortably use. Occupants confirmed the cell facilities met their requirements and that staff were attentive to their needs. All of the accessible cells were found to be clean and fresh. A safer cell was located on the ground floor of Allanton and Lamont halls. Both were not in use at the time of the inspection, but were very clean and contained the basic necessary equipment with the beds consisting of a mattress located on a concrete plinth. It was noted that the safer cell in Allanton had just been painted. All cells were fitted with adequate sanitation facilities and the intercom call points were found to be in good working order. The maintenance process worked well within the prison, prisoners were aware that they reported a fault to staff who then created a job request to the maintenance team via the “Agility” system. The job was given a priority rating and progressed, prisoners reported to inspectors that they received a good service and repairs were carried out in good time. Prisoners and staff were clear on how to report maintenance issues and were very complimentary about the effectiveness of the estates team. The maintenance programme was viewed and at the time of inspection had a 91.6% completion rate with only 6.72% jobs outstanding, this equated to five jobs and the inspectors found that all were delayed for good reason such as awaiting parts or specialist involvement. The prison maintenance team had three larger projects running at the time of the inspection, the fitting of LED lighting throughout the prison, the fitting of a macerator machine in the waste system and an upgrade to the hot water system.
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29 2.2 Good levels of cleanliness and hygiene are observed throughout the prison and procedures for the prevention and control of infection are followed. Cleaning materials and adequate time are available to all prisoners to maintain their personal living area to a clean and hygienic standard. Rating: Satisfactory performance The prison was found to have very good levels of cleanliness throughout and cleaning schedules for the prison in general and residential halls were in place. The industrial cleaning team were responsible for cleaning most areas of the prison. This team was considerably smaller than it was pre-COVID-19, but the quality of the staff was high. Hall pass men were responsible for cleaning the residential areas. Prisoners were encouraged to keep their cells tidy and those that were unable, were assisted by hall pass men. Relevant training records were kept by the prison including prisoner’s biohazard and British Institute of Cleaning Sciences (BICS) qualifications, and there were sufficient cleaning materials held on the halls. The industrial cleaning staff were responsible for the training of hall pass men, the green pass cleaners for specific areas in the prison and those from the work party. Prisoners spoken to confirmed that they had received relevant training and were confident in their work. Each hall had at least one pass man trained in dealing with biohazard incidents. Inspectors requested to view the cleaning process and found that the contents of the biohazard kits varied in every hall. When requested, the majority of staff produced an outdated kit and were not aware that an up-to-date grab box was available for use. However, when these grab boxes were inspected some were found to be missing essential content. Recommendation 3: Biohazard kits throughout the prison should be refreshed and communication improved to make staff and prisoners aware of availability and access for use. 2.3 All prisoners have a bed, mattress and pillow which are in good condition, as well as sufficient bedding issued by the prison or supplied by the prisoner. The bedding is also in good condition, clean and laundered frequently. Rating: Generally acceptable performance A number of prisoners beds, mattresses and bedding were inspected and found to be in good condition. Some prisoners reported that the mattresses were too thin but they had the ability to request a replacement mattress at any time. Their name would be placed on a list and each hall was allocated three mattresses a month to distribute. If a prisoner required a mattress in an emergency one would be provided. Inspectors were informed that a three-year mattress replacement programme was underway.
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30 The prison laundry worked well with efficient processes in place. The laundry work party consisted of 24 prisoners pre-COVID-19 but was operating adequately at the time of inspection with a team of six. Laundry staff reported that the washing machines were over 10 years old and starting to show their age but a replacement programme was anticipated to be starting soon. Induction training was provided by staff working in the laundry and a workshop training record was kept. Work wear, personal clothing and bedding can all be washed at the laundry. Prisoners put items in a net bag and place them in a large container on each hall for collection three times a week. It was noted by inspectors that the net bags were sealed by tying a sock around the neck, and prisoners reported that they recovered their laundry by identifying their bag by the sock. There was no fixed process in place for recovering lost laundry items, prisoners were advised in the information packs provided during the admission process that items placed in the laundry system were done so at their own risk. A small number of prisoners complained to inspectors that laundry bags often went missing. Laundry staff were not aware of this being an issue and a check of prison systems showed that there had been no complaints made regarding laundry over the preceding six months. Recommendation 4: Numbered ties for securing laundry bags should be provided so prisoners property can be identified. 2.4 A range of toiletries and personal hygiene materials are available to all prisoners to allow them to maintain their sense of personal identity and self-respect. All prisoners also have access to washing and toileting facilities that are either freely available to them or readily available on request. Rating: Satisfactory performance Prisoners were given free access to essential toiletries on the halls and inspectors found adequate items in stock on all residential areas. In addition, the prison canteen offered a good range of toiletries to suit all budgets. Inspectors were informed that there had not been a PIAC in respect of the canteen since February 2020 due to COVID-19 restrictions. Inspectors were pleased to hear that a PIAC was scheduled for the end of June 2022 and prisoners would be given the opportunity to influence the items available to them. All cells within HMP Shotts had showers and toilets therefore prisoners were free to use them whenever they pleased. The washing facilities in the accessible rooms were excellent with plenty of space and access points. The proposed upgrade of the hot water system will ensure the continued provision of sufficient washing facilities in the future. There was a sufficient stock of towels that were in good condition and laundered regularly.
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31 2.5 All prisoners have supplied to them or are able to obtain for themselves a range of clothing suitable for the activities they undertake. The clothes available to them are in good condition and allow them to maintain a sense of personal identity and self-respect. Clothing can be regularly laundered. Rating: Satisfactory performance All prison issued clothing was held in the store room located on each hall. Inspectors found sufficient stocks of clothing in all sizes in all halls, and there was a combination of new and recycled clothing available with additional stock held in the laundry. Prisoners reported that they knew the process in respect of requesting clothing and receive it with little or no delay. It was noted that jeans were limited in number on some halls and staff explained that this was due to the supply being suspended due to COVID-19 restrictions. It was found that demand for jeans had, however, dropped therefore any shortage was not proving to be an issue. It may be that the current rule of prisoners not being required to wear jeans during visits is a contributory factor and this may change should this rule be revoked in the future. Outdoor jackets were of high visibility and good quality, with prisoners reporting they were fit-for-purpose. There were adequate jackets in stock and available if required. Prisoners were permitted to wear their own clothing in residential areas to allow them to maintain a sense of personal identity. See QI 2.3 in respect of information about the laundry. 2.6 The meals served to prisoners are nutritionally sufficient, well balanced, varied, served at the appropriate temperature and well presented. Meals also conform to their dietary needs, cultural or religious norms. Rating: Poor The meals provided were on a three-week set menu cycle. Meals were ordered through the new Kiosk system, which clearly displayed nutritional information and allergens contained in all choices. However, any special dietary needs were ordered separately and tracked by the catering staff, due to the Kiosk system requiring further updates. Additionally, prisoners reported some issues in regards to re-ordering when the same choice(s) was wanted in future weeks. It was also reported by catering staff that amendments to the menu were not possible until the system was fully updated. Catering staff identified several groups of prisoner who were following cultural or religious dietary requirements. However, one prisoner with significant health concerns required more substantial adjustment, and as such, a bespoke menu which retained variety and met their nutritional needs had been created for them. This was seen as good practice, being able to resource and accommodate a tailored service for those who needed, whilst achieving a high volume output service function that was key to the establishment.
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32 Overall cleanliness of the pantries was generally good. However, both sections of Lamont Level 1 and 2 could be improved. These areas consistently showed signs of waste food products from the previous day’s meals. Additionally, whilst checking equipment a significant number of microwave ovens were found to be corroded, with the potential for flaking debris to contaminate food during cooking. Disappointingly, it appeared that this was identified during internal auditing in February this year, but had not yet been addressed. The internal audit appeared to have been very robust and identified a number of issues which remained as actions still requiring to be addressed. A significant number of prisoners expressed dissatisfaction with the overall quality of food in HMP Shotts, with most stating that it was ‘soggy’ or ‘stodgy’. The food trolleys were witnessed being loaded and sent to the halls as close to meal time as possible, and there was equipment within the pantry areas (air fryers) to re-fresh some products but, on such a scale this would seem impractical. The food trolleys appeared to be common to other establishments with the exception of HMP Low Moss, where the food trolleys more effectively maintain the condition of food arriving at the halls. Point of service for meals appeared a little less consistent across the establishment. Although some areas appeared to be carrying out temperature checks at the point of service this was not witnessed in all areas. Additionally, very few prisoners serving food were observed wearing the appropriate PPE. Only one area was observed securing the pantry door to prevent unwarranted access during meal service. Indeed, on a number of occasions and locations, the pantries were found to have numerous prisoners preparing their own food whilst service was on-going; and on more than one occasion servers were observed eating whilst serving. In multiple locations some items, such as soup, custard and salad were placed on a dining table where self-service appeared to be the norm. This was concerning for potential cross contamination as well as portion control (a prisoner was observed moving between sections because custard had run out in their section). Training records were reviewed and showed that only 77% of prisoners working in the Catering Department had completed the required Food Hygiene certification. Of those prisoners listed for pantry duties, this was found to be slightly less than 50% trained in Food Hygiene, which may be reflective of their awareness to wearing PPE and not eat whilst serving food. Indeed, catering supplies were checked and there appeared to be an abundance of PPE available. Catering staff absence had affected, and remained an issue for the Catering Department and requisite training. Good Practice 2: Catering staff provide consultation and provision for those with additional dietary necessities. Recommendation 5: HMP Shotts should ensure Kiosk updates are completed timeously to prevent frustrations with the ordering of special diets. Recommendation 6: HMP Shotts should ensure all prisoners involved in food production or service are appropriately trained to carry out these duties.
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33 Recommendation 7: HMP Shotts should ensure that all food is served by the appropriate person who must always be wearing appropriate PPE in conditions that comply with all Food Hygiene requirements. HMP Shotts should also ensure consistent checking and recording of food temperatures. Recommendation 8: HMP Shotts should replace all equipment which has signs of corrosion, or equipment which is known to be faulty. Recommendation 9: HMP Shotts should implement the required actions from previous catering audit in February 22, and re-audit to measure compliance. Recommendation 10: HMP Shotts should review their delivery equipment from the Catering Department to Halls to ascertain if improved heat holding can be achieved, and subsequently deliver a better quality product at point of service.
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34 STANDARD 3 - PERSONAL SAFETY The prison takes all reasonable steps to ensure the safety of all prisoners. All appropriate steps are taken to minimise the levels of harm to which prisoners are exposed. Appropriate steps are taken to protect prisoners from harm from others or themselves. Where violence or accidents do occur, the circumstances are thoroughly investigated, and appropriate management action taken. Inspection Findings Overall Rating: Generally acceptable Performance In this standard, one quality indicator was rated as good, two were rated as satisfactory, and four were rated as generally acceptable performance giving an overall rating of generally acceptable performance. There were four examples of good practice and 10 recommendations for improvement. The prison had largely emerged from the limitations and consequences of COVID-19, and it felt safe and ordered. Prisoners managed under Talk To Me (TTM) were managed with care, compassion and understanding. TTM case files checked had some gaps in relation to completion and HMP Shotts should continue to take action to improve this. In relation to taking care of prisoners whose appearance, behaviour or background left them at heightened risk of harm, the positive impact the introduction of photocopying of prisoners’ mail had in mitigating the risk of illicit substances being introduced to the prison was acceptable. The experiences of staff in 2021 in managing those under MORS appeared to be such that the staff placed even greater value on the 40% reduction pro rata in cases so far in 2022. A multi-disciplinary approach was being applied to support those at heightened risk of harm due to mental health and/or substance misuse. Residential staff were able to identify and signpost to appropriate stakeholders and there were opportunities for prisoners to self-refer to available health improvement activities. A prisoner information channel (PIC) was a major feature of Fife College’s contribution to health improvement activities, in collaboration with various internal and external partners. Custody Adjustment Support and Transition (CAST) Pathway within the NIC had at its foundations, residential staff and Physical Education Instructor (PEI) based delivery of induction, accredited START programme and other training courses with input from Fife College, the Health Improvement Practitioner and other stakeholders. .
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35 Procedures in support of violence reduction strategy were evident across the establishment. However, it was noted that the SPS Anti-Bullying Strategy ‘Think Twice’ required to be re-invigorated. There was a fully equipped C&R store and a well organised Command Room, supported by comprehensive contingency plans. COVID-19 had affected competencies, with the suspension of training with only 20 of the required 31 C&R trainers in post. Worryingly, in common with other establishment, there was a lack of any desktop or live exercise within the past 12 months, with the last Local Incident Management (LIM) exercise pre-dating COVID-19. The Health & Safety Management system in place was found to be compliant, managed by two qualified part-time Health & Safety Managers responsible for providing competent advice. However, fire evacuation drills should re-commence as soon as reasonably practicable, supported by briefings where necessary to ensure staff are proficient in procedures. In terms of the PANEL principles for this standard: Participation. TTM practices were person-centred. Individuals were encouraged to participate in case conferences and staff/prisoner relationships appeared good and supportive. There were opportunities for positive engagement by those otherwise at risk of harm or abuse from others through self-referral, multi-disciplinary meeting or by embracing the health improvement activities offered. Accountability. Compliance processes for assuring essential procedures in caring for those at risk of suicide or self-harm including the SPS Suicide Strategy - TTM, Management of an Offender suspected to be at Risk due to the ingestion of a Substance (MORS) and Notification of Concern (NOC) were highly efficient and well managed. The TTM system was well established and there was a robust assurance process was in place that reported monthly to SPS headquarters. Documentation was completed to a high standard and any slippages were identified and actioned through the assurance process. As COVID-19 restrictions reduced, there had been monthly Multi-disciplinary Team meetings. Meetings were well attended, and minutes demonstrate they were prisoner focussed. It was noted that the SPS Anti-bullying Strategy ‘Think Twice’ required to be re-invigorated. Non-discrimination and equality. Although the establishment demonstrated a positive approach to equality, the recently planned Equality & Diversity meeting had not taken place and should be convened at the earliest opportunity. Empowerment. Most of the prisoners reported feeling safe and the prison was well ordered with staff demonstrating control. Prisoners provided feedback that the information on prisoner information channel (PIC) had been useful quoting the use of breathing exercises. There was evidence of prisoners reporting being bullied and the perpetrators challenged.
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36 Legality. The application of the Prisons and Young Offenders (Scotland) Rules appeared legitimate at the time of inspection, with no evidence found of any non-compliance in terms of procedures observed and checked. The Health & Safety Management System was mature and provided a good basis for culture. Encouraging observations Compliance processes assuring essential procedures in caring for those at risk of suicide or self-harm including TTM, MORS and NOC were highly efficient and well managed. Health Promoting Friday incorporating ‘Neil’s hugs foundation’, ‘library man group’ and ‘trauma (NHS information session), etc., in collaboration between Fife College, SPS and NHS Mental Health Team, Health Improvement Practitioner and Addictions Caseworker and North Lanarkshire Council. Open to mainstream and protection prisoners (full parity). Prisoner Information Channel. Podcasts from positive peers, Enhanced Addictions Caseworker, NHS advertisements, mental health support, meditation, self-help, music requests, etc. Fife College. Use of Library in mental health provision. “Education and conversation in Art classes”, work with men with speech and language communication deficits, low literacy learners and dyslexia friendly learning. Residential Officer and Physical Education Instructor based delivery of Custody Adjustment Support and Transition (CAST) Pathway within the National Integration Centre (NIC) incorporating induction, training courses and case conferencing with input from Fife College, Health Improvement Practitioner and other stakeholders. Management of Health & Safety across Prisoner Employment and Training department including risk assessment, safe systems of work and training arrangements. Emerging concerns SPS HQ should reinstate Psychological input into CAST Pathway case conferencing within the NIC. There should be improved administration around completion of TTM case files. A regular review of violence reduction should be reintroduced. All VIR forms following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document. The SPS Anti-bullying Strategy ‘Think Twice’ should be re-launched with information and training provided as only 40% of staff had been trained since July 2021 Posters require to be replenished across the establishment in relation to on the ‘Think Twice’ and violence reduction. Staff were not always clear on processes to follow after a staff alarm and should be reminded of correct protocols Conduct a review of incident command role holders to ensure adequate cover for the establishment, and that role holders are competent.
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37 Contingency exercise arrangements to be reviewed. There had not been any Contingency exercise arrangements within past 12 months with the last Local Incident Management (LIM) exercise pre-COVID-19. Fire evacuation drills should re-commence as soon as reasonably practicable supported by briefings where necessary to ensure staff are proficient in procedures. Due to the length of time since the last Noise Assessment taking place, this should be reviewed in line with policy by a competent person.
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38 Quality Indicators 3.1 The prison implements thorough and compassionate practices to identify and care for those at risk of suicide or self-harm. Rating: Generally acceptable performance Prisoners managed under the SPS TTM Strategy in HMP Shotts were managed with care, compassion and understanding. Information shared between the NHS and the SPS at case conferences was appropriate and justified in terms of respecting confidentiality, whilst managing the individual’s risk of suicide and self-harm. In an observed case conference, it was noted that the prisoner was only given access to the case file ten minutes before the conference, resulting in frequent objections to some of the information recorded in the case file. The residential First Line Manager (FLM) who chaired a case conference was not a regular SRU FLM. Whilst a residential officer was present, it was apparent that the Chair lacked direct knowledge of the prisoner which could affect the ability to assess risk and any changes needed to the care plan. One individual had been managed on TTM for an extended period of time. An attempt to remove the individual from TTM and manage him under the SPS self- harm policy some time ago had been unsuccessful, but it was encouraging to see arrangements being made for a multi-disciplinary meeting to consider options again. Compliance processes were highly efficient and well managed in assuring essential procedures in caring for those at risk of suicide or self-harm including TTM, Management of an Offender suspected to be at Risk due to the ingestion of a Substance (MORS), Notification of Concern (NOC) and the operational readiness of Crash Packs (first-aid kits). TTM live case and reception risk assessment (RRA) audits covering the previous three months were reviewed and most reported all being in order and no action being required. Some actions had been identified such as the pre-case conference healthcare assessment taking place at the same time as the case conference and signatures must be added. Actions had been taken to communicate and correct these issues, however during a review of live TTM cases files the pre-healthcare risk assessment had been recorded at the same time as the case conference. There were also some good examples of the process working where a change of circumstance form was completed indicating an increase of maximum contact intervals from 60 minutes to 15 minutes. Action taken to ensure consistency with family engagement was also evident.
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39 Minutes from quarterly local suicide prevention meetings over the past nine months were evidenced, and information was shared from the Suicide Prevention Coordinator forum at SPS HQ. Safer cells were regularly used for prisoners being managed under MORS and this was evidenced with nine safer cell checklists reviewed between February and March 2022. The procedure surrounding completion of a checklist prior to a safer cell being used appeared well established and was confirmed by the assurance process. MORS was found to be well administered with examples reviewed; the procedure appeared well established and assurance checks were evidenced. Three listeners were operating in the prison and was an appetite to increase the number of listeners through recruitment and training irrespective of how often listeners were being accessed by the prisoner population. Recommendation 11: HMP Shotts should ensure that prisoners are given the opportunity to access information on their case file prior to the case conference. Recommendation 12: HMP Shotts should be proactive to encourage all prisoners on TTM to have family engagement and continue to take action to improve administration matters around completion of TTM case files. 3.2 The prison takes particular care of prisoners whose appearance, behaviour, background or circumstances leave them at a heightened risk of harm or abuse from others. Rating: Good performance A PEEP list was provided and the requirements of individuals spoken to confirmed they should be on the list. Officers demonstrated good knowledge of the individuals and the background behind their requirements. It was clear that the introduction of the photocopying of prisoner’s mail had reduced the risk of illicit substances being introduced to the prison. In the first three months of 2022 there were 46 occasions of prisoners being managed under MORS compared to 312 occasions in 12 months of 2021. This represented a 40% reduction pro rata. There were two individuals who were refusing to return to main circulation. There was good evidence of positive engagement with officers and the NHS mental health team who were attempting to persuade them to engage with the rest of the population. It was encouraging to attend a Prisoner Management meeting, where they were attempting to transfer both individuals. Multi-disciplinary Substance Misuse Meetings started in January and took place monthly as had Multi-disciplinary Mental Health Team Meetings. These were well attended, purposeful and an ‘information from prison officers’ section provided officers with the opportunity to raise concerns about individuals in an appropriate forum, with relevant stakeholders present. Minutes of both meetings referred to
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40 liaison with the NHS Mental Health Team, which was an obvious strength in both meetings. It was clear from speaking to a range of staff that a Health Improvement Practitioner and Enhanced Addictions Caseworkers were making significant inroads in communicating with prisoners on both physical and mental health and addiction services through a number of initiatives. All opportunities to engage with the prisoner population were being utilised including a four-week course shared as a podcast on the prisoner information channel (PIC) with prisoners providing feedback that they had been using the information shared such as ‘rest and repair’ breathing exercises. The Offender Outcomes Unit Manager further intended to introduce ‘Recovery and Support Representatives’ to assist in support of peers. Foreign national prisoners reported feeling safe and having their basic needs met. Reception and Link Centre, in delivering induction procedures, demonstrated use of global language services both via telephone and in person. Fife College in the Learning Centre also aided foreign national prisoners with ESOL courses. Fife College in collaboration with the SPS, NHS Mental Health Team, Health Improvement Practitioner, Enhanced Addictions Caseworker and North Lanarkshire Council. Good examples include the NIC Custody Adjustment Support and Transition (CAST) programme for individuals sentenced to eight years and above; Health Promoting Friday’s incorporating ‘Neil’s hugs foundation’; ‘library man group’ and ‘trauma (NHS information session). Management plans were focussed on reintegrating individuals into mainstream environments where they had earlier displayed vulnerabilities. An excellent Lamont Hall and NIC management plan was evidenced from December 2021, comprising seven stages of a person-centred approach ranging from planning and engagement with NHS, providing the individual increasing time in hall to integration and induction following a consolidation phase allowing reflection and exploration of issues. Good Practice 3: Multi-disciplinary approaches in Health Promoting Friday incorporating ‘Neil’s hugs foundation’, ‘library man group’ and ‘trauma (NHS information session), etc. Good Practice 4: Prisoner Information Channel. Podcasts from positive peers, Enhanced Addictions Caseworker, NHS advertisements, mental health support, meditation, self-help, music requests, etc. Good Practice 5: Residential staff and PEI based delivery of CAST Pathway within the NIC incorporating induction, training courses and case conferencing with input from Fife College, Health Improvement Practitioner and other stakeholders. Recommendation 13: SPS HQ to reconsider with Psychological Services, return of psychology input into CAST Pathway case conferencing within the NIC.
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41 3.3 Potential risk factors are analysed, understood and acted upon to minimise situations that are known to increase the risk of subversive, aggressive or violent behaviour. Additionally, staff are proactive in lowering such risks through their behaviours, attitudes and actions. Rating: Generally acceptable performance Violence reduction and anti-bullying posters were visible throughout the prison. The Violence Reduction Strategy was available on the SharePoint site accessible to all staff. HMP Shotts has a Violence Reduction Group (VRG) that reviews violent and serious incidents that occur. Although well attended, the last meeting took place in September 2021. During that meeting they reviewed the last five months’ intelligence and incidents which highlighted a number of recoveries. Further information such as the updates from the halls contained useful information. One violent incident that occurred was tracked in terms of the violence reduction strategy flowchart. A comprehensive Residential FLM and Duty Manager overview had been provided on the VIR form, and a Violent Incident Review panel was awaited. The strategy document requires the VIR to be submitted to the Intelligence Management Unit (IMU) within 48 hours after a Violent Incident Review panel is completed. The IMU advised this was not the case on every occasion, but it was assuring that the IMU track and issue reminders until the Violent Incident Review panel is completed, and form submitted. A very organised IMU was delivering a well-developed SPS Intelligence Framework and action dissemination, with proactive and engaging IMU FLM and analyst staff. A strategic threat assessment was evidenced which identified current threats to the establishment along with regular Tactical Tasking and Co-ordination Group (TTCG) meetings. A prisoner profile was under development for the violent incident that had occurred. Recommendation 14: The Violence Reduction Group should meet more regularly to review violence reduction and ensure actions are taken, and the VIR form submitted to IMU following a Violent Incident Review Panel should be taken to the Violence Reduction Group meeting for consideration as required by the strategy document. 3.4 Any allegation or incident of bullying, intimidation or harassment is taken seriously and investigated. Any person found to be responsible for an incident of bullying, intimidation or harassment is appropriately reprimanded and supported in changing their behaviour. Rating: Generally acceptable See QI 3.3 relating to the Violence Reduction Strategy that provided the prison with a coordinated approach to reducing violence. In the absence of a Violence Reduction Group meeting since September 2021 there is a general acceptance that
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42 the SPS Anti-bullying Strategy ‘Think Twice’ required to be re-launched to ensure staff were aware and knowledgeable. One ‘suspected bullying report (SBR) form’ from April 2022 was reviewed and actions taken found to meet the standard’s requirements. Of the six violent incident report forms submitted since September 2021 relating to prisoner-on-prisoner assault, on five of the six occasions, individuals were separated and on two of the occasions a transfer was arranged for a perpetrator. An induction package ‘respect me’ along with autism awareness and disability as well as hate crime courses were delivered within the NIC. Consideration should be given to rolling these packages out to the wider prison population, beyond the dissemination that occurs as men move from the NIC to general population. Up until March 2020 a training programme was in place for the SPS Anti-bullying Strategy ‘Think Twice’, with 40% of staff recorded as trained at that time. COVID-19 had affected this. SPS Anti-bullying Strategy ‘Think Twice’ was included in the induction package, which continued to be bespoke at this time as the prison emerged from COVID-19 and was covered in the induction booklet provided. It was encouraging to attend a Prisoner Management meeting, and see the robust approach to prisoner need. Recommendation 15: SPS Anti-bullying Strategy ‘Think Twice’ requires to be re-launched to overcome the identified deficits e.g. only 40% of the staff are trained. Posters should be replenished across the establishment and a re-audit of incidents should take place to ensure all incidents of bullying, intimidation or harassment are investigated and taken seriously. 3.5 The victims of bullying or harassment are offered support and assistance. Rating: Satisfactory performance A number of opportunities for prisoners to appropriately raise concerns or be identified by staff were evidenced against QI 3.2. Similarly, good staff/prisoner relationships were demonstrated across the establishment which created an environment where concerns were more likely to be raised with staff. An example of this was observed on one hall when eye contact with a prisoner at meal time raised suspicions with staff that something was amiss. The officer took the opportunity later to speak with him out of sight of other prisoners. In the NIC inspectors observed an FLM meeting with a prisoner who was in prison for the first time, where concerns had been raised in relation to demeanour. Whilst no concerns were identified in relation to bullying or harassment, the FLM was able to offer him support with the impact that missing his family was having on him.
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43 In most occasions the perpetrator of an assault was relocated and only one occasion the victim was moved. 3.6 Systems are in place throughout the prison to ensure that a proportionate and rapid response can be made to any emergency threat to safety or life. This includes emergency means of communication and alarms, which are regularly tested, and a set of plans for managing emergencies and unpredictable events. Staff are adequately trained in the roles they must adopt according to these plans and protocols. Rating: Generally acceptable performance SOP 202 ‘security staff alarm response’ was provided and described primary and secondary alarm responders, that were not specifically designated. Personal alarms carried were separate to the staff radio system. Inspectors noted that SOP 202 ‘security staff alarm response’ was past its review date and should therefore be reviewed. SOP 909 relating to medical emergencies during patrol and night shifts was also provided, including reference to code red and code blue arrangements along with arrangements for contacting the Scottish Ambulance Service. There was a fully equipped control and restraint (C&R) store in preparation for any eventuality. The equipment store was well managed, in support of a very organised command room and further supported by comprehensive contingency plans, log operating system and CCTV facilities. Contingency plans evidenced that there were nominally sufficient number of incident command role holders to enable HMP Shotts to deal with level two and three incidents, and a good assurance process that checked that there was suitable staffing in place. There was no evidence of any desktop or live contingency exercises within the past 12 months, and the Local Incident Management (LIM) exercise pre-dated COVID-19. Whilst accepting the impact of COVID-19, a review should be conducted to ensure command role holders are adequately trained and contingency exercise recommenced. HMP Shotts had recently appointed a new Staff Training Manager who was still in the process of verifying numbers trained in role and competency relating to C&R refresher training dates. He reported that COVID-19 had further affected competencies with only twenty of the required thirty-one C&R advanced trained staff in post. Recommendation 16: Conduct a review of incident command role holders to ensure consistent and adequate cover for the establishment and that role holders are adequately trained. Recommendation 17: Contingency exercise arrangements to be reinvigorated.
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44 Recommendation 18: Rapid planning is required to ensure a full complement of advanced C&R trained staff are in post in readiness for a proportionate and rapid response to any emergency threat. 3.7 The requirements of Health and Safety legislation are observed throughout the prison. Rating: Satisfactory performance Signed policy statements recognising management responsibility for Health & Safety (H&S) and Fire Safety were provided. A Risk Assessment register was available which could be sourced in the prison SharePoint site along with an excellent suite of risk assessments and safe systems of work (SSOW). The site could be accessed by all staff and on reviewing some examples, regular review periods were demonstrated. Fire risk assessments were evidenced with signatures of the Governor in Charge and Health and Safety Manager. Those responsible for H&S had the required qualifications to carry out their role professionally. There had been no Scottish Fire & Rescue Service or Health & Safety Executive activity in recent years and no respective audit actions. Excellent workplace inspection records existed, which showed all departments being inspected monthly between April 2021 and April 2022, except one department on two separate occasions. An assurance report was completed weekly by FLMs that included quality of cell searches, operational readiness, checks of crash packs and C&R equipment. It incorporated a Unit Manager check and contributed to an assurance regime, as did completion of three PRL audits on a monthly basis, co- ordinated by the Business Improvement Department. These scheduled programmes created a culture of assurance and contributed to the compliance and H&S agenda across the prison. H&S Committee had met of six occasion in the previous fifteen months. Whilst minutes of two meetings held in 2022 evidenced union and senior management attendance, it was evident that there was no FLM, residential officer or estates manager in attendance. The H&S Committee should consider inviting them to attend in order to ensure appropriate consultation with all employees. Accident investigation procedures were in place where responsible managers were provided 14-days to return an investigation into any reported accident. Evidence provided relating to fire evacuation exercise, were from 2018 and subsequent records advised that the Governor in Charge had instructed exercises be postponed as a result of COVID-19. No evidence of replacement activities such as briefings or toolbox talks was provided. The culture of H&S was observed within the workshops as outstanding and an example of good practice, particularly arrangements around machine safety, signage, risk assessment and training. Work units and outside areas visited were clean to a very high standard, role modelled by the whole team responsible for the department.
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45 An impressive training regime was evidenced covering a number of prisoner training courses that included H&S manual handling, fire awareness, hand-injury awareness and emergency response. Safety documentation available included risk assessments and SSOWs that had been reviewed in the past 12 months, along with noise assessments where the hazard had been identified. Although these assessments should have been reviewed in 2021. A ‘Shotts safety tracker’ was evidenced with some open actions relating to a lack of first aiders from 2021 and an issue from 2018 relating to prisoners using bedding they had been able to purchase/be issued, which didn’t meet rating standards in line with the SPS Fire Safety Manual and UK fire prevention regulations. HMIPS recommend action is taken to progress and appropriately close these actions. Good Practice 6: Management of H&S across the regimes department including risk assessment, SSOW and training arrangements. Recommendation 19: Fire evacuation drills should re-commence as soon as reasonably practicable, supported by briefings where necessary to ensure staff are proficient in procedures. Recommendation 20: Noise Assessments should be reviewed by a competent person.
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46 STANDARD 4 - EFFECTIVE, COURTEOUS AND HUMANE EXERCISE OF AUTHORITY The prison performs the duties both to protect the public by detaining prisoners in custody and to respect the individual circumstances of each prisoner by maintaining order effectively, with courtesy and humanity The prison ensures that the thorough implementation of security and supervisory duties is balanced by courteous and humane treatment of prisoners and visitors to the prison. Procedures relating to perimeter, entry and exit security, and the personal safety, searching, supervision and escorting of prisoners are implemented effectively. The level of security and supervision is not excessive. Inspection Findings Overall Rating: Satisfactory performance In this standard, one quality indicator was rated as good performance, six were rated as satisfactory performance and three were rated as generally acceptable performance, giving an overall rating of satisfactory performance. There was one example of good practice and six recommendations for improvement. HMP Shotts felt secure with regards to security both within the residential areas, regimes buildings and around the perimeter. There was a good suite of relevant SOPs available to assist staff in their understanding of what was required to carry out their role. There was also good evidence of assurance processes and risk assessments. HMP Shotts was still working through the consequences of the COVID-19 restrictions, with low numbers attending work or education. As restrictions ease the numbers moving around the prison will increase. Staff will need to adjust to the large movement of prisoners, particularly those who have joined since the pandemic and have not experienced this before. A priority for HMIPS is to encourage HMP Shotts to increase staff that are competent in Control and Restraint (C&R) and Personal Protection Training (PPT). In terms of the PANEL principles for this Standard: Participation: It is fundamental that prisoners feel part of the process and not the subject of it. This was evident when looking and observing reintegration or management plans for the SRU, self-representations at discipline hearings and case conferences, as well as case conferences relating to Special Security Measures (SSM). Prisoners reported that they had been communicated to with regards to decision taken about them, and were aware how and when to challenge these decisions as seen in one discipline hearing. Accountability: Individualised reintegration plans were evident where discipline hearings were observed. Judgements and punishments were on a case to case basis with no apparent use of a tariff system. There were assurance systems in place for sample cell and area searching, but this was not always completed. There was robust assurance in regard to vehicle and perimeter searching with good
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47 assurance processing place. There was a process in place to assure that C&R removals were legitimate and lawful, however some planned removals had not been recorded and were not mitigated by the Head of Operations. Non-discrimination and equality: There was no evidence of any discrimination against prisoners. There was no evidence of targeting of particular prisoner cohorts either in searching or drug testing. It was pleasing to see the care taken with those that were most at risk to ensure that their rights were upheld and that measures, such as those reported in QI 4.4, were only in place for the minimum amount of time. Empowerment: Discipline hearings and case conferences supported prisoners in allowing them to understand the actions taken against them. There was time taken to explain decisions and the actions prisoners could take if dissatisfied with any outcomes. Inspectors found that generally prisoners understood why they were being managed in a certain way, and what was expected of them to turn their situations around, particular when being managed under rule 95 Legality: For this standard it was clear that prisoners held under various rules or procedures were done so lawfully. With regards to the possession of illegal items, the prison was proactive in restricting the introduction of these items both through the vehicle lock and the perimeter. Although there is a caveat of COVID-19 and the importance of social distancing, it was found that in some cases staff involved in a C&R removal were past their refresher dates. However, the removals were carried out as per C&R guidelines. Encouraging observations The areas around the perimeter were clear of rubbish, maximising the opportunity to recover illicit items thrown over the perimeter. Emerging concerns HMP Shotts should look to increasing the C&R competency of their staff to the accepted level as a priority. HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation The Prison Monitoring and Assurance Group (PMAG) should intervene and take the decision as to where a prisoner should move to when it is clear that prisoner cannot be reintegrated into the holding prison. HMP Shotts should ensure that all cells are searched at least once per quarter and consider carrying them out at different times.
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48 Quality Indicators 4.1 Force or physical restraints are only used when necessary and strictly in accordance with the law. Rating: Generally acceptable performance. Force or physical restraint, known as Use of Force (UOF) must be undertaken in accordance with Rule 91 of the Prisons and Young Offenders Institutions (Scotland) Rules 2011. UOF did not appear to be overused. All were checked by the Head of Operations to ensure compliance, with an initial check carried out by the IMU. Any trends or hotspots where UOF had been used were then highlighted to the Tactical Tasking and Coordination Group for any action. Staff were guided by a UOF SOP as well as an SOP regarding the video recording of removals, a requirement when the removal is planned. Both SOPs were accessible via the local SharePoint site. The IMU kept a database of all removals, along with any video footage linked to planned removals and it was retained for the required three-year period. The camera used to record UOF was stored in an area easily accessible by an FLM. Ten UOF were checked from the last 12 months. The report writing was of a good standard and highlighted any issues staff experienced, when change overs occurred and the reasons as well as where staff were replaced to uphold the guidelines about searching. On three occasions when the UOF was planned, there was no footage available and no mitigation offered. On a number of occasions nurses were not available to assess the prisoner once the removal was completed. This was either due to the time of the removal i.e. after 18:00 when there were no NHS staff in the prison, or due to NHS staff shortages. However, there was evidence that C&R removals had been recorded when checking the IMU data base. An inspector also viewed a live removal from the Electronic Control Room (ECR). It was clear that it was managed well with the removal being recorded. Under SPS PRL 2.3.4.2: Control & Restraint, only prison staff assessed as competent to do so took part in C&R removals. A concern for HMIPS was the level of staff competence in C&R. Staffed trained in C&R phase one was at 53% with C&R phase 2 at 86%, and those required to be competent in PPT was at 16%. Staff involved in UOF were checked against staff training records. Two FLMs supervising a removal and seven staff who took part in a removal were out of competency. However, this was during COVID-19 where social distancing was being adhered to and C&R training had not taken place. Staff competency in C&R needs to be addressed as a priority. Recommendation 21: HMP Shotts should increase the C&R competency of staff to the accepted level as a priority.
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49 Recommendation 22: HMP Shotts must ensure that all planned removals are recorded unless there is reasonable mitigation. 4.2 Powers to confine prisoners to their cell, to segregate them or limit their opportunities to associate with others are exercised appropriately, and their management is effected with humanity and in accordance with the law. The focus is on reintegration as well as the continuing need for access to regime and social contact. Rating: Generally acceptable practice When inspectors visited the SRU it was almost at full capacity. This had been the case for some time other than for short periods where numbers had dropped slightly. When inspecting the SRU, 14 prisoners were located within the Unit. Nine were on rule 95(11), three on rule 95(12), including one prisoner on special security measures (SSM), and two were on a refusal to return to association (RRA) following the end of their rule, one of which had been on a RRA for a 92 days. A sample of rule 95(11) and 95(12) rules were checked on PR2 where prisoners had been in the SRU for between 18 to 116 days. All prisoners were found to be held lawfully, case conferences, self-representations and narratives had been downloaded into the Community Integration Plan (CIP) on PR2. The narratives were of good quality and there was at least one record for each week. If something significant occurred this was recorded at the time. Each prisoner had an individualised reintegration plan for returning to a residential area or their move to another SRU. However, there appeared to be some difficulty in moving prisoners out of the SRU, even to their prison of allocation. One example showed the prison attempting to move a prisoner to a number of prisons without success. Work needs to done to assist in moving prisoners between SRUs, The Prison Monitoring and Assurance Group (PMAG) should take a more active role in deciding transfers, preventing long term stays in SRUs and inhibiting the potential for a return to normal location. Prisoners reported a good understanding of their situation and confirmed that they had received their entitlements of access to fresh air, a shower, the satellite gymnasium and the phone, with most having access to in cell telephony. All prisoners had access to visits as well as a virtual visits console within the Unit. However, prisoners could not access evening visits due to the SRU being on patrol. The SRU had a reasonable book and CD library along with a selection of clothes and trainers for those who arrived with no belongings. There were a number of prisoners held under rule 95 in the residential areas, their regime was checked and confirmed that they were receiving their entitlements. HMIPS were informed that recently the prison had increased the operational capacity to include some cells in the SRU. If a prisoner was removed to the SRU and placed on a rule 95(11), his cell was cleared and filled by a transferred prisoner and therefore no longer allocated to him. If it was deemed appropriate to revoke the rule earlier than planned it was difficult to re-integrate the prisoner as he no longer had a cell to go to, and therefore prisoners may be held in the SRU longer than necessary.
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50 HMIPS are of the view that the SRU cells should not be part of the occupancy level of a prison. Every prisoner allocated to that prison must have a cell to return to at whatever time was deemed appropriate and not risk being kept in an SRU longer than necessary. Recommendation 23: The PMAG should intervene and take the decision as to where a prisoner should move to when it is clear that a prisoner cannot be reintegrated into the holding prison. Recommendation 24: SPS HQ should consider reducing the occupancy levels at HMP Shotts so as not to include the SRU. 4.3 The prison disciplinary system is used appropriately and in accordance with the law. Rating: Satisfactory performance HMP Shotts had held approximately 550 disciplinary hearings since the 01 January 2022. It was reported that since the introduction of photocopying prisoners personal mail the number of disciplinary reports had reduced. During the inspection a number of hearings were observed and were found to be well run. Where prisoners were included, they articulated that they understood the process, confirmed they had received the charge within the specific time and were clear on the outcome. Where a punishment was deemed appropriate they understood how to appeal the outcome. Where a prisoner challenged the legality of the report, the adjudicator suspended the hearing in order for an investigation to take place. The paperwork was completed as per SPS guidelines on disciplinary hearings 2018, and although some of the narratives could have been more explanatory the adjudicators worked well with the information they had. A local adjudication audit is carried out by the Deputy Governor on 10 random cases per month. This audit revealed a number of examples where the paperwork was not up to standard and was actioned to remedy the mistakes. The Deputy Governor also ensured he observes at least one disciplinary hearing for each adjudicator annually. A recent PRL audit undertaken in April 2022, indicated 100% compliance, with good narratives and evidence downloaded. Inspectors also observed the process undertaken where a prisoner did not wish to attend and had pleaded guilty in their absence. This process was followed well. 4.4 Powers to impose enhanced security measures on a prisoner are exercised appropriately and in accordance with the law. Rating: Satisfactory performance HMP Shotts had six prisoners on enhanced or SSM in the past 12 months and had a useful SSM flowchart to ensure compliance with the policy. During the inspection there was only one person on SSM, who was located in the SRU and had been under these measures for an extended period of time. The SSM was well
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51 documented and had described various stages of these measures, from having to have three officers attend to him wearing full PPE to a stage where he was being managed under normal SRU conditions unless he left the Unit. At this point he was subjected to the hand cuffing policy and this measure was accepted as the correct action to take at this stage to manage his risk. Reading the narratives, it was clear that risk assessments had continued to be utilised in efforts to reduce the SSM. The prisoner had attended most cases and there was evidence that there was a person centred approach. Inspectors attempted to engage with the prisoner but he declined. 4.5 The law concerning the searching of prisoners and their property is implemented thoroughly. Rating: Generally acceptable practice The regularly searching of prisoners and their property is necessary to ensure the safety and wellbeing of all prisoners and staff, and to minimise the threat to stability of the prison. It is the HMIPS view that it is also important that searching is not targeted to certain individuals without due cause. HMIPS were content that this was not an issue at HMP Shotts. Recently, the process that all cells should be searched at least once every quarter had been reintroduced after a period of time during the pandemic where the SPS had reduced searching significantly in order to adhere to social distancing. All areas had a searching record that annotated when cells and areas were searched, and although there was a weekly audit carried out by a residential FLM to ensure compliance, the completion of quarterly searches had not always taken place. Apart from tactical searching most prisoners and their property appeared to be searched at the same time every day. This could present a risk whereby prisoners could ensure their cells were clear of any illicit items during this time. HMIPS would ask HMP Shotts to consider carrying out quarterly searches at random times of the day rather that at the same time. An SOP on prisoner searching was available for staff to reference in SharePoint, which outlined the requirement for any search to be person-centred and to encourage positive engagement. Due to limited opportunities to observe a search this was not tested. When asked, prisoners confirmed that searches had taken place, that it was to help keep them safe and that they had been conducted fairly. There was no evidence of any complaints around searching. The National Dog Unit was utilised regularly and was on site during the inspection. However due to its workload, booking them to attend could be difficult. When possible, the prison uses them to search cells, mail, staff and prisoners as well as visitors. They can also be used purely as a deterrent, and its HMIPS view that it would be beneficial if the prison had their own dog unit to utilise on a daily basis. Recommendation 25: HMP Shotts should ensure that all cells are searched at least once per quarter and consider carrying them out at different times.
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52 4.6 Prisoners’ personal property and cash are recorded and, where appropriate, stored. The systems for regulating prisoners’ access to their own money and property allow for the exercise of personal choice. Rating: Satisfactory performance HMP Shotts transferred prisoners in from other prisons, therefore property and personal cash was already recorded in the SPS systems. All property arriving in reception was checked but not always in the presence of the prisoner. Due to COVID-19 restrictions still being in force, space was limited. If there were more than two prisoners arriving at the same time, prisoners did not stay in reception other than to fulfil the basics requirements of the admission process. This allowed prisoners to be removed from the escorting transport as quickly as possible. After completing the property check, the prisoners card was brought to the residential area to be signed by the prisoner. There did not appear to be any issue with prisoners not being present, but the reception will revert to previous practice once guidelines allows. Any issues the prisoner had about missing items was dealt with by a residential officer. In most cases there would be a request for the previous property card to be scanned to the prison to check against what had arrived. It would be helpful if it was common practice for a copy of the previous property card to be included with the transfer documentation. One issue that reception found was there were no national items in use list. This could cause issues, particularly when a prisoner arrived from another prison with items not permitted in HMP Shotts. Prisoners were able to access their property through a request book on the hall, which was supported by an SOP that outlined the various reasons why prisoners may wish to do so. Any property arriving in the reception was dealt with when time allowed, normally on the same day which resulted in no back log. Single items such as a watch were taken up to the prisoner for allocation, with items such as footwear required to arrive at reception before being replaced. This process was a result of previous incidents where prisoners had not handed in their old footwear. Any cash arriving in the mail was managed through a robust recording system. Prisoners family and friends could transfer money electronically which arrived at SPS HQ. The amounts received were then distributed to each prison, and the prisoners personal cash account updated. In both cases the money was in the prisoners account on the same working day. Due to COVID-19 restrictions it was not possible at this time to hand in cash or property at the prison. This meant that families had to pay for deliveries and it was difficult if purchases need to be returned, which could also be costly. The valuable property is held in a bag in a lockable cabinet, and were individually listed on the prisoner property card. However, these bags were not sealed. New bags had been purchased with seals but were not large enough to hold some prisoner’s valuables. New bags had been ordered.
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53 The key for the valuables cabinet was kept in a safe with a pin code. However, this was accessible by multiple staff, including the night shift manager, where the car keys were held. When HMIPS raised the risk of too many staff having access to the safe the prison reacted positively and purchased another safe for reception use only. Recommendation 26: SPS should consider including a copy of the sending prison property card with the transfer documentation. 4.7 The risk assessment procedure for any prisoner leaving the prison under escort is thorough and implemented appropriately. Any restraint imposed upon the prisoner is the minimum required for the risk presented. Rating: Satisfactory performance The risk assessment procedure for any prisoner leaving the prison under escort was thorough and implemented appropriately. An FLM, when picking the escorts, ensured that the person in charge was out of probation. Gender balance was also taken into account for searching and medical procedures. The FLM carried out an assessment of the escort using PR2, and also consulted the enhanced escorting list for those requiring special procedures. The list had good information to help understand the issues that could arise while out on escort. A personal escort approval certificate/risk assessment was attached to the PER. The sheet included information of the past history of escorts, risks factors, rationale for hand cuffing, instructions if the prisoner becomes unruly. If hand cuffs were to be removed due to a medical request, the action the escorting team should take was included. Where an enhanced escort was to take place the police were contacted. The receiving hospital was also contacted for all escorts. A review of the frequently used locations was carried out by the IMU, and although this has not been undertaken for some time, inspectors were satisfied that nothing had changed since the last review. 4.8 The law concerning the testing of prisoners for alcohol and controlled drugs is implemented thoroughly. Rating: Satisfactory Performance HMP Shotts did not test for alcohol but had a Mandatory Drug Testing (MDT) Unit. Inspectors visited the MDT which was staffed full-time Monday to Friday, by three staff. Prior to COVID-19 the prison was able to test approximately 1500 per year, and although this had dropped during the pandemic it appeared they had kept up with demand testing of 630 in 2021. At the time of the inspection they had tested 295. The MDT Unit tested prisoners for various reasons including for progression, where prisoners were tested within three months of transferring to the National Top End or open conditions, for Integrated Case Management (ICM), for enhanced work sheds, those who had been identified through intelligence reports, suspicion and on
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54 the request of a prisoner. There did not appear to be any discrimination in the testing process whether it was targeted testing or for those requiring it. Although the process was not tested in a live situation, inspectors were taken through the MDT process and were satisfied that it was fair and lawful. Staff were very experienced. They were able to demonstrate the process well and explained the steps taken dependant on the test result. There were no recent records of complaints about the MDT process. 4.9 The systems and procedures for monitoring, supervising and tracking the movements and activities of prisoners inside the prison are implemented effectively and thoroughly. Rating: Satisfactory performance Inspectors observed the movement of prisoners to work and education on numerous days during the inspection. Although numbers were not at the level pre-COVID-19, the route was well controlled and effectively supervised. FLMs from regimes were responsible for the movement off prisoners to and from the work areas. Each hall was moved in a controlled manner to minimise the risk of enemies meeting and to keep mainstream and protection prisoners apart. In most cases each work party was escorted by the officer in charge of that workshop and repeated at the end of the work period. Those going to education was picked up prior to the route moving by the education operations officers. All prisoners walked through a metal detector when leaving the residential areas and on returning from their place of work or education. All prisoners leaving work parties were hand wanded on exit and then walked through a metal detector. A percentage of which were asked to walk past the cell sense detector. If any prisoner was carrying anything of bulk, they were required to put this through the x-ray machine. There was no mandatory strip searching during route movements, but where required the prisoner was taken to the reception area to be searched. Inspectors also observed the process for moving prisoners who were at risk i.e. from the SRU, and this was also completed in a controlled manner. Good communications within the prison was observed allowing the transit of those presenting a risk to be safe. 4.10 The procedures for monitoring the prison perimeter, activity through the vehicle gate and for searching of buildings and grounds are effective. Rating: Good performance An inspector accompanied officers during their perimeter security checks, which were carried out on a minimum of three occasions per day, covering the early, back and night shift. On the perimeter checks a member of staff from each shift carry out a observational check of the perimeter fencing, with each staff member undertaking a third of a physical check known as a ‘push and pinch test’, checking the integrity of the perimeter, ensuring that a complete physical check is carried out every 24 hours.
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55 During the perimeter checks it was also observed that officers ensured that all vehicles were locked, and that there were no illicit items thrown over the walls. It was noted that there was no rubbish on view and therefore it was easy to spot packages that had been thrown over the perimeter. Any items found were placed in a production bag and sent to the IMU accompanied by a report from the officer, detailing the find. This is important in tracking the most vulnerable points for packages to be thrown over, days and times. The perimeter checks were also observed from the ECR. The ECR kept a record of checks and they were uploaded onto the SharePoint site, with an FLM checking them at least once per week. The access and egress of vehicles was observed. Staff communicated well with the drivers and ensured that they followed the guidelines with regards to identifying themselves and items not permitted i.e. personal communication devices. Once the staff member was content with the drivers credentials a thorough search of the vehicle took place, which was carried out when the vehicle left the prison. A number of search aids were at the disposal of the member of staff. When GEOAmey transport visited the prison a list of all registration numbers were available to staff, and if the number was not in the list then the transportation would be refused entry and the company contacted. A number of SOPs covering all aspects of this QI were available for reference by staff. Good practice 7: The areas around the perimeter were clear of rubbish maximising the opportunity to find items thrown over the perimeter.
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56 STANDARD 5 - RESPECT, AUTONOMY AND PROTECTION AGAINST MISTREATMENT A climate of mutual respect exists between staff and prisoners. Prisoners are encouraged to take responsibility for themselves and their future. Their rights to statutory protections and complaints processes are respected. Throughout the prison, staff and prisoners have a mutual understanding and respect for each other and their responsibilities. They engage with each other positively and constructively. Prisoners are kept well informed about matters which affect them and are treated humanely and with understanding. If they have problems or feel threatened they are offered effective support. Prisoners are encouraged to participate in decision making about their own lives. The prison co-operates positively with agencies which exercise statutory powers of complaints, investigation or supervision. Overall Rating: Satisfactory performance In this standard, one quality indicator was rated as good performance and seven were rated as satisfactory, giving an overall rating of satisfactory performance. There was one example of good practice and one recommendation for improvement. The overall impression at the time of the inspection was of a calm and well run establishment. Staff and prisoner relations appeared positive with a light and friendly atmosphere in most areas. Staff and prisoners addressed each other by their first names and appeared to have good relations. The regime was still restricted somewhat by COVID-19 however there were opportunities for all prisoner groups to spend significant time out of their cells whether attending work parties, education, PT, exercise or general association on the hall. It was noted that with the exception of mealtime numbers checks, the halls were generally unlocked for most of the day. This was appreciated by the prisoners having been restricted for much of the last two years. Activities such as education and PT are timetabled by flat to preserve the internal COVID-19 bubbles. This has worked well and has been scheduled to limit clashes where a particular flat would have two activities offered at the same time. There continues to be disruption within the work parties due to offender outcomes staff being deployed to the halls to cover staff shortages in the residential areas. This is in turn limiting opportunities for prisoners to engage in meaningful activities on a regular basis. In addition, there are no opportunities for protection prisoners to engage in enhanced workshops that would increase their wage earning potential. The PIC is very impressive and contains a broad mix of programming interspersed by adverts and announcements for internal courses and opportunities. In addition, it carries instructional videos to assist prisoners with using the kiosk system and carrying out a lateral flow test among other things. During the inspection there were no IPMs on site however staff and prisoners were aware of who they were and information on how to contact them was displayed
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57 clearly in all halls. It was stated by one individual in particular that having left a message on the prison phone system the IPMs got in touch quickly to discuss his issue. Prisoner Complaint Forms were freely available on all flats and there was a robust recording system in place to track the complaint from beginning up to external remedies where required. In terms of the PANEL principles for this Standard: Participation. Prisoners were fully involved in the ICM and Risk Management Team (RMT) process with regard to pre-release and progression. Families were invited to participate in the ICM process at the behest of prisoners. There had been no PIAC meetings since the start of COVID-19 and this had led to a reduction in user voice with regard to the current regime. Accountability. Progression was a common complaint and echoes the number of complaints received by HMIPS where progression is seen as unfair. Delays in assessment and offending behaviour programme availability are issues for both HMP Shotts and SPS HQ. Non-discrimination and equality. The current regime for education, PT and programmes allows equal opportunity for all prisoners to attend these sessions. Protection prisoners did not have the opportunity to attend the enhanced work party and were therefore denied the chance to increase their wage earning potential. Empowerment. Given that the population of HMP Shotts was long-term prisoners, the opportunities for support and engagement was clear across the establishment. Legality. There were no issues found around this point. Encouraging observations The current regime has been designed to minimise clashes between education, PT and exercise sessions. This reduced the times where an individual would have to forgo one activity to attend another. The PIC currently in use was of a very good standard and was well maintained by two individuals, with support from the education department. Emerging concerns A Recovery Café and Whole Mind Café were previously facilitated in the Tabernacle (TAB) within the Links Centre to support individuals with addiction and mental health issues. Since COVID-19 began these had not been held. Not all prisoners fit to work were currently required to do so. This had raised some concern with regard to motivating individuals when a return to a full regime was implemented. Certain work parties were also operating sporadically at times due to shortages in the residential areas. Programme delivery currently runs alongside the national waiting lists which could cause delays in getting programmes started due to availability of transfers
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58 from other establishments to fill the classes. This was having an impact on the number of courses that can run in the year. This is causing concern for all prisoners.
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59 Quality Indicators 5.1 The prison reliably passes critical information between prisoners and their families. Rating: Satisfactory performance Prisoners were afforded the opportunity to phone their family by the hall staff/manager following transfer. This was particularly important for individuals returned to closed conditions from HMP Castle Huntly, as generally these transfers were not pre-planned and the opportunity to contact family prior to transfer would be limited. Discussions with residential staff evidenced that contact between prisoners and families was such that it would more often be the prisoner who was passing information to staff in respect of ill health or bereavement of a family member. This information was generally received by the prisoner or a request would come from outside, usually via the ECR, for the individual to phone home. It was suggested that in the majority of cases the prisoner would be expecting such news and would be prepared for it. The hall staff would discuss this situation in private and remind the individual of support available including the chaplaincy service and listeners. In the event of a death of a relative, the relevant paperwork would be commenced and used to confirm details and inform the process should the individual request to attend the funeral. Family members were regularly invited to participate in the RMT process, and the sharing of this information was conducted following written confirmation from the prisoner. The prisoner provides the details of who they wished to be invited into this process. Information was available on hall notice boards advising prisoners that Families Outside could offer assistance to register and set up friends and family on the Virtual Visit platform. The Link Centre officer and Family Contact Officer (FCO) promoted family contact through physical and virtual visits, and could link with Families Outside to support friends and families if required. Information from the Links Centre Officer suggested that they work with the FCO promoting and supporting family contact. This was facilitated through the induction process and in the visitors waiting area where staff interact with friends and family prior to visit sessions. There was no FCO on duty during the visit as one was on leave and the other had been reassigned to another role due to staff shortages; worryingly this appeared to be an ongoing situation. 5.2 Relationships between staff and prisoners are respectful. Staff challenge prisoners’ unacceptable behaviour or attitudes and disrespectful language or behaviour is not tolerated. Rating: Satisfactory performance. During discussion with both staff and prisoners there was a reciprocal feeling of mutual respect and healthy relationships. There were no issues around
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60 unacceptable behaviours or language during the visit. Interactions were jovial and good natured. An individual had a request regarding when he would receive an Xbox that he had ordered, staff contacted the reception and were able to provide an update that the item was in reception and would be issued later in the day. The prisoner was content that this had been checked and that there was a positive outcome. A number of visits to the SRU by the team throughout the inspection reported that relationships appeared to be generally positive, and that the area was calm and the staff appeared relaxed and confident. Offender Outcomes staff appeared to have positive relationships with those in the work party. All individuals were engaged in their respective tasks and the workshops had a general air of productivity with a relaxed atmosphere. There were no obvious examples of inappropriate interaction during the visits. Two sheds were closed due to staffing issues in the halls. This had been a regular occurrence. 5.3 Prisoners’ rights to confidentiality and privacy are respected by staff in their interactions. Rating: Good performance During the visit there were various interviews being conducted on the halls from chaplaincy support, the Imam and NHS colleagues. All of these interactions were conducted in side rooms offering appropriate levels of confidentiality and privacy. Prisoners also sought and were granted permission to use these rooms while conversing with the inspection team. During discussions, interview room doors were closed in order that the conversations or treatments remained private. Prisoners were called down to the desk by name however no details of what they were required for were relayed in this manner. This information was passed once the individual had reached the main desk. In most cases the individual was aware of who was looking for him or where he was required to go, i.e. visits/surgery. White boards and desks appeared clear of individual’s personal details and paperwork. 5.4 The environment in the prison is orderly and predictable with staff exercising authority in a legitimate manner. Rating: Satisfactory performance There appeared to be limited interactions between staff and prisoners, however they were conducted in an appropriate manner. While some individuals were at work or at exercise at various times during the inspection, those left on the hall appeared to be content filling their time with social activities such as pool and snooker or in the company of their peers either in cell or in the communal areas. Those on the hall were happy to report that they spent more time out of cell in general association with the current regime than before COVID-19. They were generally only locked up for a numbers check prior to meal times.
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61 Following complaints HMIPS received regarding staff dealing with an incident in the NIC earlier this year, CCTV was viewed and the incident was explained by the IMU manager. It would appear from the footage that this situation could have escalated had it not been for the swift and professional actions of staff. There were no concerns that this incident was dealt with in a heavy handed way and staff acted appropriately given the seriousness of the situation. Throughout the visit staff interacted with prisoners in an appropriate manner and were happy to take time to discuss any issues with an individual and explain the rationale behind the decision making process. There were issues around the restricting of work parties either due to social distancing in the workshops or Offender Outcomes staff being utilised to run the residential regime. This led to a stop/start approach in some work areas which was unsettling for individuals who relied on routine. 5.5 Prisoners are consulted and kept well informed about the range of recreational activities and the range of products in the prison canteen as well as the prison procedures, services they may access and events taking place. The systems for accessing such activities are equitable and allow for an element of personal choice. Rating: Satisfactory performance Various posters were displayed on noticeboards advertising support groups such as AA/CA/Recovery Café/Whole Mind Café. These were accessed by asking hall staff to contact the relevant facilitators. At present only AA and CA were taking place. The Recovery Café and Whole Mind Café had been curtailed due to COVID-19 and had yet to restart. There were further outlets for information sharing on the hall kiosk system. Staff on duty at the time appeared not to be well informed about the system or how to access it. The most that they could confidently do was print out menus which was done on an app on SPIN terminals not on the kiosk. No one had a staff login that could demonstrate the options available. One prisoner was asked to demonstrate the system and was very competent and complimentary about its functionality. He shared that the younger prisoner group were supporting those that were not as well versed with technology. There was a PIC available to all that had been very well set up by two prisoners. This PIC automatically plays a weeks’ worth of content. It was set up to show various programmes from documentaries to comedy shows and films. In the “ad breaks” between shows the two individuals who run the system had made short presentations showing education opportunities/courses/how to videos for the kiosk system and lateral flow testing among other information. The clips were animated to keep them engaging for the target audience. The system also played podcasts created in education which again had added graphic content to make them more
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62 appealing to the viewer. This is considered good practice and a model that could be copied in other establishments. Good Practice 8: PIC showing clips including how to use the kiosk systems 5.6 Prisoners have access to information necessary to safeguard themselves against mistreatment. This includes unimpeded access to statutory bodies, legal advice, the courts, state representatives and members of national or international parliaments. Rating: Satisfactory performance Copies of prison rules were available from staff in the halls for prisoner use. In addition, the prison library was well stocked with reference materials including: Prison Rules and Directions, European Prison Rules, SPS Operating Standards, Prisoner and Criminal Procedure Act, Data Protection information, European Convention on Human Rights Legislation. Legal representative visits were booked and accessed through the visit area. These appointments were conducted either face-to-face or virtually. In general face-to-face visits were conducted in the closed visit area, however legal representatives requiring to go through paperwork could request a larger non-segregated area in which to conduct the meeting. During the inspection the area was visited twice and on both occasions it was virtual meetings taking place. These appeared to be progressing with no technical issues. Court appearances could also be conducted in this area via a dedicated video link. During the visit period there were no court hearings viewed. 5.7 The prison complaints system works well. Rating: Satisfactory performance Prisoner Complaint forms (PCFs) were freely available in halls and staff were aware of where to find them on SharePoint should they require more copies. The process, stages and relevant timescales were displayed within the halls on noticeboards. Some individuals were less than assured by the complaints process and stated that they would ask for a photocopy of the complaint in order that they could evidence submission of the form as they often disappeared. As there was no paper trail in this instance there is no way to confirm if it was actually happening. Staff on the flats would, in most cases, attempt to resolve any issues prior to the need to submit a formal complaint. HMIPS highly recommends extending the use of the kiosk stem to include a complaints process. A selection of PCF 1 and 2 forms were sampled. They all appeared to be well managed. A date stamp on the front of the form indicated when the complaint had been received from the FLM and further action dates such as Internal Complaints
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63 Committee (ICC), GIC, etc. These appeared to be followed through in a timeous manner up to the completion of an ICC where appropriate. The spreadsheet allowed for tracking of the complaint through to the Scottish Public Service Ombudsman (SPSO) for action. The responses appeared to be relative and proportionate to the complaint. There were instances of multiple complaints from the same individual on a similar vein submitted on the same day. All of them were answered individually and appropriately. Once a complaint had been received the details were logged on a spreadsheet and scanned to a file on SharePoint. The spreadsheet was completed for all stages of the process and any complaints that were still active were highlighted in red text. On at least one occasion, related to the removal of a mobile phone, the governor upheld the reasoning of the ICC in rejecting the appeal however indicated that the handset should be returned to the individual to allow continued family contact. Recommendation 27: Consideration should be given to extending the kiosk system to include an electronic complaints process. 5.8 The system for allowing prisoners to see an Independent Prison Monitor works well. Rating: Satisfactory performance All halls had information displayed promoting the services available and contact details of the IPMs. IPMs could also be contacted for free via the PIN phone system and the prison issue mobiles. Individuals spoken to during the visit reported that the system was working well and IPMs responded to messages in a timely manner. While information was displayed on notice boards there did not appear to be numbers displayed around the PIN phones. There were no IPMs on site during the visit however prisoners did comment that there were frequent visits and the IPMs were visible within the establishment.
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64 STANDARD 6 - PURPOSEFUL ACTIVITY All prisoners are encouraged to use their time in prison constructively. Positive family and community relationships are maintained. Prisoners are consulted in planning the activities offered. The prison assists prisoners to use their time purposefully and constructively and provides a broad range of activities, opportunities and services based on the profile of needs of the prisoner population. Prisoners are supported to maintain positive relationships with family and friends in the community. Prisoners have the opportunity to participate in recreational, sporting, religious and cultural activities. Prisoners’ sentences are managed appropriately to prepare them for returning to their community. Overall Rating: Generally Acceptable In this standard, three quality indicators were rated as good performance, four were rated as satisfactory performance and seven were rated as generally acceptable performance, giving an overall rating of generally acceptable. There was one example of good practice and eight recommendations for improvement. The prison offered an appropriate and sufficient range of high quality employment opportunities to prisoners. Prisoners engaged well in their work parties including the enhanced work parties which supported a commercial contract. Some work parties were cancelled frequently as staff were required for operational duties. As a result of COVID-19 restrictions there had been no new registrations for vocational qualifications in the past year. All prisoners were made aware of the system for paid work as part of their induction process. The Shotts Employability Board (SEB) met weekly to review applications and allocated prisoners to work parties. All prisoners were happy with the system for applying for and changing their work placements. The SEB did not keep eligible applicants on a waiting list for future opportunities. Prisoners were required to reapply every Monday if they were still interested in a work party opportunity. The Learning Centre provided a welcoming, bright and comfortable environment for prisoners to engage in learning. Prisoners and staff worked well together and prisoners valued their positive relationships with staff. Learning and teaching was of a high quality and purposeful. Induction was not compulsory and with no follow up was a missed opportunity to welcome prisoners to education and to highlight all that the Learning Centre had to offer. Staff did not always take prisoners previous qualifications, knowledge and experiences or barriers to learning into account when discussing their future learning. The prison offered a sufficient range of physical and health education opportunities, and these were available to all prison populations. The Physical Training Instructors (PTIs) were proactive in responding to the individual needs of prisoners who accessed the gym. The range of provision was limited and did not engage all prisoners. Due to COVID-19 restrictions no prisoners had gained sports and fitness accreditation.
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65 All prisoners had access to a well-stocked library, which took account of cultural and religious backgrounds. The librarian and passman were skilled, knowledgeable and proactive in promoting the library. Feedback on the library rules, stock, service and environment were captured, displayed and responded to. Nominated by the prisoners, the library assistant received recognition as the staff member of the year in the Fife College 2022 awards. A number of prisoners participated in a range of self-help and peer support opportunities. Prisoners produced the STIR magazine, a high quality art publication with contributions from all prisons. Prisoners who participated in art classes produced high quality work culminating in a number of successes at the Koestler Awards. All prisoners had access to a range of events prior to the pandemic. Over the past two years, these were limited but plans were in place to resume them in the near future. HMP Shotts were offering prisoners the opportunity to attend fresh air for a minimum of one hour per day, including those on isolation due to COVID-19 and the SRU. Access to fresh air was on a rotational basis offering different times across the week. Due to the poor turnout on the morning sessions a recommendation has been made to encourage participation by providing afternoon sessions every day. Although pastoral care was not available daily, requests and referrals were being dealt with in good time. The visitors centre had a welcoming feel to it, staffed by a FCO and Getting Better Together Shotts (GBTS) with an information loop on the TV and literature available for visitors. Interaction between staff and visitors was positive. During the visit sessions staff were not intrusive, whilst adhering to their security responsibilities. Access to normal visits consisted of five, 45 minute visits sessions available to book monthly. Uptake for morning and afternoon sessions was low. The father and child visits appeared particularly popular with a variety of toys and game activities available. However there were some complaints that father and child visits could be difficult to access. It was pleasing to report that HMP Shotts had recently increased the session from 12 to 18 prisoners; however even with the increase in spaces the evening sessions were fully booked. Accordingly although the overall number of visit opportunities seemed to meet the needs of the population, some sessions were poorly utilised and others over-subscribed. There were plans to introduce the video visit facility into the residential areas which could improve uptake. Those on restricted visits (closed) were managed appropriately with regular reviews in place. HMP Shotts provided a range of therapeutic treatments and cognitive development, as well as social and relational skills training activities, to all those at HMP Shotts as well as accommodating those on the national waiting lists. However there was some criticism voiced by prisoners that the lack of accessibility to courses prior to their critical dates ‘window’ was delaying their opportunity to gain progression or parole at the earliest time possible. During the inspection there were 100 ICM cases outstanding. The ICM co-ordinators were prioritising those individuals who required a pre-release or pre-parole case conference. The ICM co-ordinators were very enthusiastic and knowledgeable and were motivated to increase their own
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66 throughput and eradicate the backlog. It was reported that in some cases the ICM coordinators would complete Personal officer paperwork to meet ICM deadlines. Personal Officer lists were found in every residential area, which were linked to a master list held on the HMP Shotts SharePoint site. Some areas had the list posted on the prisoners notice boards, but in other areas these were only on the noticeboard in staff offices. HMP Shotts should ensure that Personal Officer lists are clearly posted where all prisoners can see them. The process for managing those on an Order for Lifelong Restrictions (OLR) and the Multi-Agency Public Protection Arrangements (MAPPA) worked well with good communication between partner agencies. In terms of the PANEL principles for this Standard: Participation: Prisoners were given the opportunity of work through a SEB on a one to one basis. Although there were some good examples of prisoners receiving individual support and mentoring to enable them to participate in work parties, there was also evidence where previous qualifications, knowledge and experiences or barriers to learning of prisoners were not taken into account. Prisoners who did not attend induction missed the opportunity to understand what was on offer as there was no follow-up communication later. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities. Any prisoner who requires an annual case conference although not approaching their critical dates is asked if they wished a case conference. If they do, then an ICM is arranged. Accountability: The education department took into account the prison regime to minimise timetable clashes. Staff monitored the Library footfall, using the focus group findings to increase usage. Although HMP Shotts had a Family Strategy plan, this was now requiring a review due to being more than five years old. Regular case reviews of OLRs are carried by the Psychology department along with the personal officer, ensuring any new information is captured and is recorded in the national data base. Any new risks can then be identified to the Parole co-ordinator/Life Liaison Officer and a case conferences for referral is made to the RMT or MAPPA. Non-discrimination and equality: Educational opportunities were provided for all prisoner regardless of classification. There were some restrictions on protection prisoners attending enhanced work parties. Cultural events were vastly reduced due to COVID-19 but with the commencement of the Equality and Diversity Group in March 2022, plans were in place to return to the pre-pandemic timetable. The new Kiosk system was now in operation throughout the prison, with a range of languages on it, however not all prisoners were aware of this function. Prisoners were able to access a range of worship opportunities for different faiths including Muslim and Buddhist services however staff shortages did impact on these services. Only those visitors deemed as a risk were placed on closed visit, all other visitors were allowed open visits with prisoners, allowing prisoners children to see their father during child/father visits.
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67 Empowerment: Generally, most prisoners understood their rights for employment and the opportunities for education. Education focus groups allowed prisoners to suggest changes to timetables and subjects on offer and also ran focus groups twice yearly to understand the needs of their clients. Unfortunately, there was no evidence that the same process was in place for physical activity. Although there had been a Children’s Visits Activity Plan in place, this had now ended. HMP Shotts recognises the value of involving prisoners and their families in developing a new plan by arranging focus groups, however this had not yet taken place. Legality: Although the prison rules (82) state that all prisoners should work, this is not compulsory at HMP Shotts. During the Inspection, both residential halls offered all prisoners at least 60 mins of time in the fresh air to all prisoners. All prisoners managed under closed restrictions were done so in accordance with the Prison Rules. Encouraging observations Good examples of prisoners who were ‘not yet ready’ to participate in work parties being identified and supported well by their Personal Officer to work towards being able to participate. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities Emerging concerns The number of work parties cancelled as staff were required for alternative prison duties Those not attending Education Induction should be followed up COVID--19 restrictions had prevented prisoners gaining sports and fitness accreditation. Registration for vocational qualifications had stalled There were no processes in place to consult with prisoners to take account of individual interests and needs to inform future programmes. For example, for those older adults and those with additional needs. The high number of outstanding ICM case conferences Prisoner perceptions of delays in progression or parole caused by limited access to offending behaviours programmes
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68 Quality Indicators 6.1 There is an appropriate and sufficient range of good quality employment and training opportunities available to prisoners. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The prison offered an appropriate and sufficient range of high quality employment opportunities to prisoners. These included work parties for gardens, laundry, catering, wood assembly, wood machine, engineers, bike shed, occupational, textiles, recycling and charity. The prison also provided employment for pass men in the residential halls, the education centre and gymnasium. Prisoners engaged well in their work parties including the enhanced work parties that supported a commercial contract. The prison had previously offered an extensive range of vocational training opportunities prior to COVID-19 restrictions. All prisoners were made aware of the available work parties at induction and all eligible prisoners were encouraged to attend a work party although employment is not compulsory. All eligible prisoners were given the opportunity to discuss their employment opportunities on a one to one basis by attending the SEB who met weekly to review and allocate available positions in work parties. There were good examples of prisoners receiving individual support and mentoring to enable them to participate in work parties. The scheduling of employment and training opportunities had not been reviewed since the start of COVID-19 restrictions. The SEB took no account of prisoner’s suggestions for future work parties. The prison regime had changed as a result of dealing with high levels of staff absenteeism. Some work parties were cancelled frequently as staff were required for prison security duties. As a result of COVID-19 restrictions there had been no new registrations for vocational qualifications in the past year. Recommendation 28: Registration for vocational qualifications should recommence 6.2 Prisoners participate in the system by which paid work is applied for and allocated. The system reflects the individual needs of the prisoner and matches the systems used in the employment market, where possible. Rating: Generally Acceptable All prisoners were made aware of the system for paid work as part of their induction process. The Shotts Prisoner Employment Policy supported the system for the allocation of paid work. The SEB met weekly to review applications and allocate
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69 prisoners to work parties. Almost all prisoners understood the rationale of selection for paid work, although some categories of prisoners were not eligible to apply for enhanced work parties. All eligible prisoners were able to apply for employment, or request a change of employment through the SEB. Prisoners were able to attend the SEB to discuss their application and to receive feedback. All prisoners were happy with the system for applying for and changing their work placements. There were good examples of prisoners who were ‘not yet ready’ to participate in work parties being identified and supported well by their Personal Officer to work towards being able to participate. Information regarding the availability of work parties was advertised in the accommodation halls, although the prison did not systematically advertise vacancies in work parties and relied on word-of-mouth. When a prisoner’s application for a work party was unsuccessful, the SEB did not keep eligible applicants on a waiting list for future opportunities. Prisoners were required to reapply every Monday if they were still interested in a work party opportunity. 6.3 There is an appropriate and sufficient range of good quality educational activities available to the prisoners. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The Learning Centre provided a welcoming, bright and comfortable environment for prisoners to engage in learning. The centre was fit for purpose and well equipped with a range of resources including the library. Prisoners and staff worked well together and prisoners valued their positive relationships with staff. Learning and teaching was of a high quality and purposeful. Staff adapted their learning and teaching approaches effectively to meet the needs of learners who were motivated and engaged in learning. A few prisoners were making good use of resources to support self-directed study. Prisoners participated in a wide range of subjects and qualifications at Scottish Credit and Qualifications Framework levels 3-6 across 12 subject areas including Communications, ICT, and Numeracy. There were a total of 13 prisoners participating in Open University courses with five continuing and eight who had recently applied. The Learning Centre Manager (LCM) held focus groups with prisoners to gather suggestions about changes to timetables and subjects on offer. Education opportunities were promoted within the halls and on the PIC. The LCM liaised informally with other areas within the prison and took account of their timetables when scheduling classes in order to minimise timetable clashes. The prison encouraged prisoners to participate in education and they received the
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70 appropriate wage from their work party whilst they attended the learning centre. Educational opportunities were provided for all categories of prisoner with timetabled provision for prisoners on protection regimes. All prisoners were informed that they had been scheduled for an induction session to education shortly after they arrived in the prison. If they didn’t attend at this time, there was no follow-up communication. This was a missed opportunity to welcome prisoners to education and to highlight all that the Learning Centre had to offer. During induction, Learning Centre staff made prisoners aware of the range of educational opportunities available within the prison. This provided an opportunity for staff to identify and support any prisoner requiring additional learning support. However, staff did not always take prisoners previous qualifications, knowledge and experiences or barriers to learning into account when discussing their future learning. 6.4 There is an appropriate and sufficient range of physical and health educational activities available to the prisoners and they are afforded access to participate in sporting or fitness activities relevant to a wide range of interests, needs and abilities. Prisoners are consulted in the planning of activities offered and their engagement is encouraged. Rating: Generally Acceptable The prison offered a sufficient range of physical and health educational opportunities and these were available to all prison populations. A change in regime due to the impact of COVID-19 has resulted in each residential level having individual access to the gym on a daily basis. As a result, attendance has increased to approximately 100 prisoners per day. The available space was used well to facilitate the increased numbers. For example, cardio equipment was in one area and weights were in the main hall area. The PTIs were proactive in responding to the individual needs of the prisoners who accessed the gym. This included an assessment using the physical activity readiness questionnaire and induction with a PTI before accessing physical activity. Personal training plans and health and nutrition advice and information was also provided on request. Relationships between the PTIs and prisoners were strong and their experience and support was valued. Almost all prisoners who met with Inspectors highlighted the positive impact on their mental health and wellbeing as a result of participation in gym activities. Prior to the pandemic, in partnership with Fife College, a few prisoners achieved accreditation in recognition of their achievements. The satellite gyms, which mainly consisted of cardio equipment in each of the residential halls were well used. In the NIC, weights equipment was also available, used well and prisoners were supported by a prison officer. There were a few examples where PTIs have provided individual programmes for use in these areas and promotional materials for the gym were on display in all residential halls.
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71 The range of provision was limited and did not engage all prisoners. Due to COVID--19 restrictions no prisoners had gained sports and fitness accreditation. There were no processes in place to consult with prisoners to take account of individual interests and needs to inform future programmes. For example, for those older adults and those with additional needs. Recommendation 29: Sports and fitness accreditation should be recommenced. 6.5 Prisoners are afforded access to a library which is well-stocked with materials that take account of the cultural and religious backgrounds of the prisoner population. Rating: Good All prisoners had access to a well-stocked library, which took account of cultural and religious backgrounds. This included books, audio material, DVDs and electronic games. An easy read section was also in place to support those with lower level reading ability. Coloured overlays were also available to support those with dyslexia. A smaller library resource was also located in the SRU. Regular donations from prisoners, the public and West Lothian Council library service also helped to expand the library content. The use of the Dewey decimal classification system to arrange books via subject aligned well with the library systems used in communities. Library resources were accessed by attending the library or through the well- established request service. The librarian and passman were skilled, knowledgeable and proactive in promoting the library. They supported prisoners to make best use of the resources and developed new initiatives to respond to identified needs. This included the partnership with NHS to develop a self-help service in response to a growing need for support with mental health. Self-help resources were displayed well and were widely accessible, including a confidential request service where information was delivered to residential areas. Requests for resources had increased and feedback was positive, including informal feedback across the wider prison population. The library assistant had completed first aid in mental health training, which had strengthened her knowledge in this area. The library assistant regularly visited halls to distribute information leaflets and promote the library. In cell reading materials were shared and goal setting and achievements were discussed regularly with prisoners. The library assistant, with good support from the passman developed and delivered a number of other programmes or activities. For example, monthly book groups and a regular podcast took place with all content identified by the prisoners. This included, music, book reviews, information sharing and inputs from partners. Partners, such as psychological services welcomed the opportunity to share information and demystify their profession. The Friday morning ‘Minds Matters’ sessions facilitated access to advice and information in response to an increase in mental health issues. Topics included mental health, suicide prevention, addiction, trauma, meditation and regular visits from a therapet, which was very popular.
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72 Library staff recorded footfall in the library on an ongoing basis and consulted with prisoners twice yearly. This showed that footfall was increasing. Feedback on the library rules, stock, service and environment were captured, displayed and responded to. Nominated by the prisoners, the library assistant received recognition as the staff member of the year in the Fife College 2022 awards. 6.6 Prisoners have access to a variety of cultural, recreational, self-help or peer support activities that are relevant to a wide range of interests and abilities. Prisoners are consulted on the range of activities and their participation is encouraged. Rating: Generally Acceptable All prisoners had access to a range of events prior to the pandemic. Over the past two years these have been limited but plans were in place to resume these in the near future. The Equality and Diversity Group held its first meeting in March 2022 and there were plans to build on the work of this group to design a varied programme of events for all prisoners. The Kiosk system that operates throughout the prison was available in a range of languages, however, not all prisoners were aware of this function. Prisoners who participated in art classes produced high quality work culminating in a number of successes at the Koestler Awards. Sixty-four pieces of art work were entered in 2022 with a further 15 entries in relation to graphic design, poetry and creative writing. In previous years, a few prisoners successfully gained gold and platinum Koestler Awards. Prisoners produced the STIR magazine, a high quality publication with contributions from all prisons. The content, with its focus on creativity and self-expression such as body art, was relevant to the prison population. The Editorial Group, consisted of four long-term prisoners who oversaw the production of the magazine. Supported by Fife College and distributed to 13 prisons across Scotland this provided an opportunity for prisoners to achieve individual goals. Similarly, the Snapshot monthly magazine written and designed by HMP Shotts prisoners was of good quality with content relevant to their context. A number of prisoners participated in a range of self-help and peer support opportunities, including a listener service, although these were limited. A systematic and planned approach to encourage participation would have benefitted the prison population. 6.7 All prisoners have the opportunity to take exercise for at least one hour in the open air every day. All reasonable steps are taken to ensure provision is made during inclement weather. Rating: Satisfactory During the Inspection, both residential halls were found to be operating time in the fresh air to all prisoners for a minimum of one hour per day. The four periods were
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73 for set times, but this was on a rotational basis ensuring each area had access at different times across the week. The timetable for accessing time in the fresh air was found on all hall notice boards. In every area a provision of outdoor weatherproof clothing was present, which appeared to be sufficient to accommodate everyone wishing to use it. The two periods in the morning were poorly attended from both of the residential halls. Attendance at afternoon sessions appeared much more popular with the prisoner groups. Staff advised that prior to COVID-19 only two sessions operated which meant grouping areas appropriately; such as Allenton levels 1 and 2 which both house protection prisoners. During the observation of an afternoon session a number of prisoners requested access back into the hall prior to the hour ending (referred to as ‘half-time’) which staff accommodated, the remaining prisoners enjoyed their full hour. This appeared to be a common practice, and the flexibility of staff to facilitate this ensured that prisoner’s needs or preferences were accommodated. One area reported having two individuals who were isolating due to COVID-19, both of whom were consistently offered their hour in the fresh air separate from other prisoners. The SRU was also found to consistently offering a daily hour in the fresh air to all prisoners. During the inspection period, all prisoners located in one specific area were restricted from having their opportunity of an hour in the fresh air due to on-going security concerns. These restrictions were applied appropriately and in full compliance with the Prison Rules. Recommendation 30: HMP Shotts should review the exercise timetable to appropriately group areas and consider scope to provide afternoon access to all prisoners every day. 6.8 Prisoners are assisted in their religious observances. Rating: Satisfactory The timetable for the various religious services was published and on display in all residential areas. The faith centre was bright and welcoming, with good décor and suitable to arrange for a wide variety of services or requirements. The pastoral team were awaiting the arrival of a new member of staff, due around the end of May. Currently, not all days had a member of the team on duty, but all requests and referrals were being dealt with in good time. There had also been some issues with the attendance of an Imam, but this had been resolved.
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74 Unfortunately, with reduced staffing the ability to deliver additional faith studies had been impacted. Previously up to four varying study groups were facilitated annually. It was hoped that after May, staffing would allow for the recommencement of a range of faith studies. The care of the pastoral team was evident through their willingness to provide, what they describe as ‘softer’ services, not directly linked to or based on one’s faith. Their willingness not just to attend to the ‘needs’ relating to faith but, trying to ensure any ‘needs’ of any prisoner were addressed is to be commended. 6.9 The prison maximises the opportunities for prisoners to meet and interact with their families and friends. Additionally, opportunities for prisoners to interact with family members in a variety of parental and other roles are provided. The prison facilitates a free flow of communication between prisoners and their families to sustain ties. Rating: Generally acceptable The Visits Centre was a welcoming venue, staffed by an FCO and Getting Better Together Shotts (GBTS). There was an information loop on screen and literature to assist families through their interaction with the prison and wider support groups. HMP Shotts provided a Family Strategy, however the five-year plan had expired in March of this year. The plan appeared to have been last updated in October 2019, and although a number of actions were completed there remained some which were on-going. Indeed, the plan appears not to have been reviewed and updated during the COVID-19 pandemic which was surprising. The FCO provided the Children’s Visits Activity Plan which showed activities across approximately 10 weeks for health, fitness, learning or general fun for children and families. This plan had ended with no replacement but inspectors were advised that families and prisoners were being consulted for the creation of a new Activity Plan. This was confirmed by managers who stated that user voices were important and that a survey was imminent for prisoner and families to shape services in the visits. The father and child visits appeared very popular with both prisoners and families. Staff positioned themselves well to maintain appropriate observations, but did so in a manner which was not intrusive nor impacted on the fun that the children present appeared to be having. A wide variety of toys and game activities were brought into the visit room which appeared to generate greater interactions between the fathers and their children. A stark contrast to the normal family visits where paper and colouring pencils were the only activity offered. Due to the pandemic, capacity of the visits required a reconfiguration of the layout, and part of this included the removal of the soft play area facilities (at the time of the inspection this area was still being used to store excess tables and chairs). Refreshment for all visits could be purchased from a number of vending machines which appeared well stocked. There previously was a tea-bar facility but this closed prior to the pandemic and had not yet been reopened.
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75 Prisoners were entitled to book five 45-minute visits sessions per month, inclusive of one evening and one weekend session per week. However, several prisoners commented that it could be difficult to access the Father and Child visits. Indeed, normal family visits in the evening or over the weekend appeared to be prime time with session often fully booked, and some prisoners reported that if these sessions were full then they would be without a visit that week. Conversely, morning and afternoon sessions appeared to be very poorly attended with numbers extremely low. In one instance HMIPS found a session where only three visits were booked and no visitors actually attended. During the inspection restrictions on capacity were lessened, increasing the session from 12 to 18 prisoners but even with additional places the evening sessions were fully booked. Recommendation 31: HMP Shotts should prioritise creating a new Family Strategy to plan improvements going forward and complete consultations with families around development of a new Children’s Visits Activity Plan. HMP Shotts should re-instate the soft play area as soon as possible and review what activities can be provided for children during normal family visits. Recommendations 32: HMP Shotts should review availability of visit sessions and maximise places in evening and weekends which best suit prisoners and families. 6.10 Arrangements for admitting family members and friends into the prison are welcoming and offer appropriate support. The atmosphere in the Visit Room is friendly, and while effective measures are adopted to maintain security, supervision is unobtrusive. Rating: Satisfactory practice A number of observations of admitting visitors to the prison and visits sessions were carried out. At all times, staff were found to be professional, they were courteous to visitors on arrival and helpful during visits sessions. Staff were observed dealing with a visitor who had mobility restrictions and their actions ensured that during necessary security checks no discomfort was placed on the individual. Visitors for one prisoner arrived when a visit had not been booked. Staff reviewed this appropriately and accommodated the visit, which was appreciated by the visitors. During visits sessions staff were observed to position themselves appropriately to maintain good overall security supervision, but not in a manner which would appear intrusive to either prisoners or visitors. Throughout all observations, the atmosphere in the visits room was relaxed and calm with all attendees appearing to interact freely without feeling scrutinised. GBTS staff the Visits Centre, however current provision only extends to week days and Saturday mornings. Inspectors were advised that GBTS were seeking to increase funding and provide staff across all visits sessions, and HMP Shotts should support them with this. The Centre was welcoming and well provisioned to support visitors, especially those with younger children. Whilst the GBTS staff were present there was a wide variety of activities for children as well as refreshments and information for families.
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76 6.11 Where it is not possible for families to use the normal arrangements for visits, the prison is proactive in taking alternative steps to assist prisoners in sustaining family relationships. Rating: Good Within the main visits area, HMP Shotts had five video conference units which could be booked through the normal visits process by submitting a visits request. Inspectors were advised that planning was underway to move this facility into the residential halls. This would potentially increase the capacity for the visits room for those seeking in person family contact, as well as, give potentially greater accessibility and flexibility to those wishing to undertake video visits. A video conference unit was also available within the SRU. Logistically, this benefited the whole establishment without creating the necessity to alter the regime when prisoners held within the SRU booked a video visit. This also ensured minimal disruption to regular family visits where additional staff would have been deployed within the visit room specifically for security of the individual from the SRU. This was considered good practice. The video visits that were observed appeared to run without issue but again were poorly utilised, with often only one or two prisoners and there was capacity for five. One potential issue was that although the prisoner had headphones, some appeared distracted by what was happening around them in the visits room. This possible distraction could be compared to having a call in a busy workplace or crowded room. Quieter surroundings may improve uptake and enjoyment of this facility. The prisoner induction included an offer of a family/friends induction on the facilities, support and range of opportunities available in the prison, in order that families can better understand what life in the prison is actually like. Good Practice 9: Video visits for prisoners in the SRU were facilitated within the SRU, which prevented any potential disruption to the main visit area. 6.12 Any restrictions placed on the conditions under which prisoners may meet with their families or friends take account of the importance placed on the maintenance of good family and social relationships throughout their sentence. Rating: Good During the inspection, only four prisoners were listed as being under restrictions for family visits and all were reviewed at minimum monthly by committee. All prisoners who were currently being managed under closed restrictions were done so in accordance with the Prison Rules. A review of these individuals and discussions with staff evidenced that each case was assessed on its own merits and decisions were tailored to the individual and the circumstances. One such individual, previously on the closed list, was reviewed and the restrictions were removed. They are now able to enjoy open visits with the majority of their
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77 family and friends. However, one of their visitors remained a risk and was therefore banned from entering the establishment. The prisoner was offered virtual visits with this individual. This was good use of the virtual facilities to maintain the family contact. 6.13 There is an appropriate and sufficient range of therapeutic treatment and cognitive development opportunities as well as an appropriate and sufficient range of social and relational skills training activities available to prisoners. Rating: Satisfactory HMP Shotts provided an appropriate range of therapeutic treatments and cognitive development, as well as social and relational skills training activities. A number of prisoners had transferred into HMP Shotts specifically to complete a course when the national waiting list triggered their attendance. Access to all courses was available to both mainstream prisoners and those in the protection regime. The Programmes Team delivered Constructs, Self-change Programme, Discovery and Pathways. As with all Prisons in Scotland, HMP Shotts adhered to the national waiting lists for prisoner attendance on the course identified for their specific needs. HMP Shotts was one of the few prisons offering some of these courses, which created logistical challenges but also other concerns. The lists provided showed that some prisoners may have to wait a considerable time in order to access and benefit from this opportunity. A number of prisoners voiced their concerns with regards to accessing programmes. It was felt by both indeterminate and determinate sentenced prisoners that the inability to access courses prior to their critical dates ‘window’ was delaying their opportunity to gain progression or parole at the earliest time possible. A number stated that this was the “SPS’ fault” and not theirs. Additionally, there was a concern regarding the approach to implementing the national waiting list which appeared to take no cognisance of the individual out with calculated critical dates. As such, prisoners who had served extremely long periods within HMP Shotts were informed that the next available space on a course meant they required to transfer to another establishment. Some prisoner had built friendships and a peer group who supported them, it may also place further hardship on their family if they decide to transfer for a course. The same could be the position for those prisoners who require to transfer to HMP Shotts for a programme. This is not a person-centred approach. Recommendation 33: SPS HQ should review the policy for implementing a national waiting list for access to programmes and its capacity for delivering programmes against demand to ensure there is no detrimental effect on the care of individuals in custody or their ability to progress.
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78 6.14 The prison operates an individualised approach to effective prisoner case management, which takes account of critical dates for progression and release on parole or licence. Prisoners participate in decision making and procedures provide for family involvement where appropriate. Rating: Generally acceptable At the time of the inspection, it was found that approximately 100 ICM case conferences were outstanding. Currently, the ICM co-ordinators were prioritising those individuals who required a pre-release or pre-parole case conference. Those individuals who required an annual case conference, where they were not approaching any critical dates, were written to asking if they wished a case conference at this time. Where the individual requested it the ICM co-ordinators would always oblige. Where appropriate the ICM co-ordinator would seek family involvement. However, although most pandemic restrictions had been removed, approximately only one in four family members who were invited to attend actually did so. The ICM co-ordinators were very enthusiastic and knowledgeable. There was a keen motivation to increase their own throughput and eradicate the backlog. In some instances, for those approaching critical dates, the ICM co-ordinators would complete missed Personal Officer interviews to ensure that the case conference could proceed without further delay. Personal Officer lists were found in every residential area, which were linked to a master list held on the HMP Shotts SharePoint site. All prisoners were listed with a named officer identified. Some areas had the list posted on the prisoners notice boards, but in other areas these were only on the noticeboard in staff offices. HMP Shotts should ensure that Personal Officer lists are clearly posted where all prisoners can see them. Recommendation 34: HMP Shotts should ensure that, whenever possible, it is always the Personal Officer that completes the required interview and documentation for the ICM process. Recommendation 35: HMP Shotts should continue to support ICM staff to address the backlog and bring all case conferences up to date. 6.15 Systems and procedures used to identify prisoners for release or periods of leave are implemented fairly and effectively, observing the implementation of risk management measures such as Orders for Lifelong Restriction (OLR) and Multi-Agency Public Protection Arrangements (MAPPA). Rating: Good The connectivity between internal departments evidenced a good level of communication relating to those prisoners identified for progression or potential release. The ICM co-ordinators knowledge and experience had promoted effective
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79 relationships and information sharing with all partners, whether managing individuals through MAPPA or those on an Order for Lifelong Restrictions (OLR). All OLR prisoners were managed nationally by the Head of Psychology, with regular case reviews led by the Psychologist within HMP Shotts. This included meeting with the Personal Officer to discuss the individual and any potential new information and the national database recorded monthly meetings. The ICM co-ordinators liaised with the Parole co-ordinator/Life Liaison Officer where potential risks were identified through case conferences for referral to RMT or MAPPA.
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80 STANDARD 7 - TRANSITIONS FROM CUSTODY TO LIFE IN THE COMMUNITY Prisoners are prepared for their successful return to the community. The prison is active in supporting prisoners for returning successfully to their community at the conclusion of their sentence. The prison works with agencies in the community to ensure that resettlement plans are prepared, including specific plans for employment, training, education, healthcare, housing and financial management. Inspection Findings Overall rating: Generally Acceptable Performance In this standard, two quality indicators were rated as satisfactory and three were rated as generally acceptable, giving an overall rating of generally acceptable. There were two examples of good practice and five recommendations for improvement. Relevant Information for this standard HMP Shotts is the only establishment in Scotland that is categorised as a long-term prison however during the inspection there were 15 prisoners serving under four years, including recalls. The following findings therefore need to be read in the context of the following information: Most prisoners are not liberated from HMP Shotts, but progress to other prisons to prepare for release. HMP Shotts does not have the same role as other establishments in terms of preparing prisoners for their successful return to the community. The prison liberates between 60 and 100 prisoners each year, with almost all released on non-parole licence, and not subject to statutory supervision by community-based social work services. The prison has a key role in supporting and approving progression of prisoners to National Top End (NTE) establishments and the open estate. Therefore, the prison has a responsibility for preparing individuals appropriately for these important transitions. In terms of the PANEL principles: Participation: Prisoners in HMP Shotts had good opportunities to get involved in key planning processes. ICM meetings were appropriately focussed on the individual prisoner. The prisoners were encouraged to share their views about the support they may require and access to services for helping them prepare for release or progression to less secure conditions. Prisoners were encouraged to become fully involved in the completion of reports by prison staff and prison based social workers. Families were provided with relevant information on the key planning processes and were encouraged to take part in ICM meetings where appropriate, although the numbers attending were low.
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81 Accountability: The delivery of accredited programmes at HMP Shotts reflected the needs of the population. There were clear attempts to be flexible to meet individual needs and examples of innovation to further develop these programmes. There was an outstanding need to review the broader delivery of interventions with a particular focus on meeting the support needs of a prison population affected by addictions, trauma and loss. The pre-release ICM meeting was key to identifying any concerns about plans for transition. These meetings ensured that all relevant support services were aware of the individual’s circumstances and the supports needed. Non-discrimination and equality: The importance of initial case conferences as part of the ICM processes was understood by key staff and every effort was made to ensure that these meetings had all the information they needed for identifying any vulnerabilities. Accessibility issues were discussed within the Programme Case Management Board (PCMB) and solutions developed to ensure that barriers to attending programmes delivered in the establishment were removed. Empowerment: Prisoners were placed at the centre of the ICM meetings. Preparatory discussions sought to ensure they understood the process of these meetings and were enabled to contribute. The format of these meetings ensured that prisoners had an opportunity to comment or ask questions regarding sentence plans. Care was taken to ensure that prisoners understood what was being said as well as any decision and outcomes from the meeting. There was a mixed understanding among prisoners about the range of services available to them. There were also examples of variability in the quality of communication with prisoners about decision making related to their progression. As a result, some prisoners felt ill informed about plans for progression and eventual release. There was some uncertainty about what may be in place for them in terms of future community supports. Legality: There was an appropriate emphasis on meeting legal obligations and the role of community-based services in meeting the needs of individuals making the transition from custody to life in the community. Community-based social work services played a key role in ensuring that services in the community were in place to enhance the likelihood of a successful future integration. Despite this, some prisoners were unclear about plans for release and were not confident that they would have access to the support they needed, including access to appropriate housing. Encouraging observations The co-location of interventions, psychology and prison based social work (PBSW) teams enabled opportunities for case discussion and reflection. In turn this promoted understanding of each other’s role. HMP Shotts prioritised the resumption of programme delivery following the lockdown. As a result, the programme delivery team was able to progress innovations to improve the content of existing programmes.
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82 Emerging concerns HMP Shotts should explore potential partnerships to offer independent advice in relation to the issues likely to concern all prisoners due for release from HMP Shotts, e.g. financial, housing, employment. This will help to ensure that prisoners have the access they need to advice relevant for making successful plans for release. HMP Shotts should improve consistency in the role played by personal officers (POs) in supporting individuals, including attendance at pre-release ICM meetings and ongoing time with prisoners prior to release. This will promote the confidence of prisoners in the plans for their release. HMP Shotts should explore opportunities to gather evidence on the progress and outcomes for individuals liberated from the prison to inform service delivery and support continuous improvement. This will help to ensure that prisoners benefit from evidence-based approaches to the successful return of individuals from custody to the community. To help to prepare prisoners for the significant transition from custody, HMP Shotts should promote the delivery of a formal ‘life skills’ learning opportunity.
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83 Quality Indicators 7.1 Government agencies, private and third sector services are facilitated to work together to prepare a jointly agreed release plan and ensure continuity of support to meet the community integration needs of each prisoner. Rating: Generally acceptable Collaboration between agencies based within the prison was effective. Appropriate efforts were made to identify services to support individual prisoners’ sentence plans and eventual community integration needs. The pre-release ICM meeting was a key step in the process. Efficient preparations ensured the right people were involved in ICM meetings, including family and community-based services. The meetings were focussed on the individual and their plan for progression and eventual release. This included identifying support needs and how they were to be met. The Link Centre had a limited resource. Efforts concentrated on addressing potential logistical barriers to progression and eventual reintegration, including access to a bank account and accepted identification documents. This was undoubtedly a valuable service. There were few external or community-based agencies with a regular presence in the prison. There was an emphasis on, and expectation of, community-based social workers (CBSW) to engage and involve services in planning for release. Access to independent general advice such as on benefits, financial matters or housing was not available to prisoners. Recommendation 36: HMP Shotts should explore potential partnerships to offer independent advice in relation to the issues likely to concern all prisoners due for release. This will help to ensure that prisoners have the access they need to advice relevant for making successful plans for release. 7.2 Where there is a statutory duty on any agency to supervise a prisoner after release, all reasonable steps are taken to ensure this happens in accordance with relevant legislation and guidance. Rating: Satisfactory The ICM process was well established and there was a consistent approach to the efficient coordination of these meetings. There was consistent attendance from PBSW and CBSW who were both involved in the preparation of assessments to inform sentence planning and the formulation of pre-release plans. Knowledge of the ICM process among prisoners and staff was satisfactory. The involvement of POs in meetings and the overall quality of reports was mixed. POs reported that it would be beneficial for ICMs to be arranged when they were on shift. New residential officers (direct entrants) made comment that there should be more emphasis placed on PO work while they were at the SPS college for initial training, and they felt unprepared when returning to their establishment.
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84 Collaboration between PBSW and CBSW from various parts of the country was challenging. However, the experienced PBSW Team worked hard to ensure that communication was effective. PBSW staff consistently fulfilled their responsibilities in the preparation of assessments and reports to assist decision making. The social work contribution was valued. Social workers were core members of the RMT, and alongside colleagues from psychology provided relevant expertise and knowledge to support and inform defensible decision making in relation to sentence progression and access to the open estate. Assessments and reports prepared by PBSW and psychologists benefitted from the relationships staff had developed with long term prisoners. As a result, assessments and reports reflected cooperative inter-disciplinary working and were informed by the views and experiences of prisoners. Good practice 10: The co-location of Interventions, Psychology and PBSW teams enabled opportunities for case discussion and reflection which in turn ensured that there was a good understanding of each other’s roles. Recommendation 37: SPS HQ should consider whether there should be more emphasis placed on Personal Officer work during officers initial training at the SPS college. 7.3 Where prisoners have been engaged in development or treatment programmes during their sentence, the prison takes appropriate action to enable them to continue or reinforce the programme on their return to the community. Rating: Satisfactory General Programme Assessments (GPAs) continued to be undertaken by psychology staff throughout the pandemic to determine access to the most appropriate programmes. Where specialised assessments were identified as appropriate, for example domestic abuse convictions, these were completed. There was recognition by the programmes team and prison-based social work of limited capacity to complete level of service/case management inventory (LS/CMI) assessments to inform the PCMB. Staff were ambitious for the further development of a broader range of interventions. Building on what existed to address addictions and increasing the availability and accessibility of counselling for loss and experience of trauma. The programme delivery team were also piloting a programme which included a focus on addressing domestic abuse. These were encouraging developments. Prisoners were not confident about the continuity of access to programmes when returning to the community. Prisoners were frustrated by the waiting list to access national programmes and the detrimental impact this lack of access had on progression. The programmes team were proactively seeking solutions to this issue.
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85 Good Practice 11: HMP Shotts prioritised the resumption of programme delivery following the lockdown and the programme delivery team was innovating to improve the content of existing programmes. 7.4 All prisoners have the opportunity to contribute to a co-ordinated plan which prepares them for release and addresses their specific community integration needs and requirements. Rating: Generally acceptable The ICM system was well established with a clear focus on identifying and meeting the needs of individual prisoners. Staff responsible for the operation of ICMs made effective arrangements to promote the involvement of all prisoners and, where appropriate, family members, although the attendance by family members was low. The central focus of the ICM on the prisoner, meant they were encouraged and supported to voice their views. While there is an expectation that prisoners are supported by POs, this was not always happening. There were challenges due to rostering and in the timely completion of reports and updates to Community integration plans (CIPs). The regime, whereby most prisoners were locked up after tea time, did allow for PO work to be carried out but a lack of training is a concern. New POs rely on more experienced POs to learn from which is not always the most effective way of learning. Information sharing between PBSW and CBSW was effective in co-ordinating plans for release. Given the prison accommodated prisoners from all over the country, there was an emphasis on the role of CBSW in identifying and arranging appropriate community supports and involving them in planning where relevant. There was a concerted effort to provide access to drug and alcohol interventions within the prison. Appropriate oversight was provided by a group of multi-agency statutory partners. Some prisoners due for release from the prison lacked confidence about important parts of their integration plans, especially housing options and access to mental health support. None had been given any formal opportunity to develop key life skills as part of preparation for release during their sentence. Recommendation 38: HMP Shotts should improve consistency in the role played by POs supporting individuals, including attendance at pre-release ICM meetings and ongoing time with prisoners prior to release. This will promote the confidence of prisoners in the plans for their release. Recommendation 39: HMP Shotts should explore the delivery of a formal ‘life skills’ learning opportunity to help to prepare prisoners for the significant transition from custody to the community.
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86 7.5 Where the prison offers any services to prisoners after their release, those services are well planned and effectively supervised. Rating: Generally acceptable The prison did not offer any services to prisoners after their release. No information was being gathered on progress and outcomes after release to inform any future developments. Prior to release efforts were made to help prisoners engage with services to support transition to the community on release. This was usually coordinated by CBSW and link centre staff based on needs identified in the pre-release ICM meeting. Other external agencies attended these meetings where relevant, including representatives from housing or accommodation providers. Link centre staff responded directly to the needs of prisoners on an individual basis, including in relation to finances and welfare rights issues. There were limited examples of external agencies looking to establish a routine presence in the prison to build relationships with prisoners to support the transition from custody to the community. Recommendation 40: HMP Shotts should explore opportunities to gather evidence on the progress and outcomes for individuals liberated from the prison to inform service delivery and support continuous improvement. This will help to ensure that prisoners benefit from evidence-based approaches to the successful return of individuals from custody to the community.
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87 STANDARD 8 - ORGANISATIONAL EFFECTIVENESS The prison’s priorities are consistent with the achievement of these Standards and are clearly communicated to all staff. There is a shared commitment by all people working in the prison to co-operate constructively to deliver these priorities. Staff understand how their work contributes directly to the achievement of the prison’s priorities. The prison management team shows leadership in deploying its resources effectively to achieve improved performance. It ensures that staff have the skills necessary to perform their roles well. All staff work well with others in the prison and with agencies which provide services to prisoners. The prison works collaboratively and professionally with other prisons and other criminal justice organisations. Inspection Findings Overall Rating: Generally acceptable Performance In this standard, four quality indicators were rated as satisfactory performance, three were rated as generally acceptable performance, and one was rated as poor performance giving an overall rating of generally acceptable. There were three recommendations for improvement. With only one exception, performance against the quality indicators in this standard was either fully satisfactory or generally acceptable with sufficient evidence of competence against some elements of the quality indicator to not cause concern. For example, there was clear evidence of appropriate action in response to our previous recommendations and sound business planning processes. Staff were clear on their roles and what was expected of them and planning to deal with vacancies and staff absences was robust, whilst still being compassionate. Compliance with core competency training requirements had suffered significantly as a result of the pandemic, but the issue was being gripped effectively by the new Learning and Development Manager. The main concern was the lack of a structured plan for assessing how the prison operated in relation to its Equality and Diversity (E&D) obligations. The prison would also benefit from more detailed statistical monitoring to safeguard against unintentional bias in the operation of systems affecting employment and educational opportunities or responses to complaints and prisoner indiscipline. While the GIC had helpfully begun a process of engagement with unit managers and some of the people who reported to them, we encourage further efforts to consolidate communication and engagement with front line staff. There is also a need to ensure managers give greater priority to the completion of staff appraisals. In terms of the PANEL principles for this Standard: Participation. The suspension of PIACs during the majority of the pandemic was disappointing as it significantly restricted the ability of prisoners to contribute to any discussion or decision making about the running of the prison
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88 regime. While the need to comply with COVID-19 related guidance around social distancing, etc., is fully recognised, there were parts of the prison where PIACs could have been held in line with Public Health Scotland guidance. Accountability. To their credit, the prison had unquestionably taken decisive action to address the areas of poor performance identified in the previous HMIPS inspection report. Understandably staff training to support their roles within the prison and maintain core competency had been significantly impacted by the pandemic. The prison estimated it would take a year to achieve full compliance again with core training which was a concern, particularly in relation to control and restraint procedures, but the prison had a clear plan for addressing that. Non-discrimination and equality. While the prison spoke eloquently of what it had done before the pandemic to promote Equality and Diversity, the lack of any up to date structured plan to assess and promote E&D at the time of our inspection was a major concern. It is imperative that the whole agenda around E&D is swiftly re-energised. Empowerment. While staff-prisoner relationships were witnessed by inspectors as positive and respectful throughout the prison, the length of the gap in the running of any PIAC during the pandemic left a concern about the commitment to empower prisoners to participate and claim their entitlements. Without an effective system of PIACs and focus groups it is difficult to see how prisoners can feel that their voice matters. Nevertheless, at the time of our inspection PIACs had begun to be re-established. Legality. There were no issues in relation to this standard regarding upholding the legal rights of prisoners as set out in domestic and international laws. Encouraging observations Respectful staff – prisoner relationships, with motivated committed staff. The swift and effective response by management to investigating and responding to some issues raised by inspectors during the inspection and clear evidence of action to address previous inspection recommendations. Emerging concerns The lack of a structured plan for assessing the extent to which the prison currently meets its E&D obligations and where improvements are necessary. Difficulties achieving core training competency levels due to operational restrictions posed by the pandemic. The loss of opportunities for prisoners to inform or influence decision making during the pandemic when PIACs were suspended. The need to improve communication and engagement with front line staff, building on recent helpful initiatives by the GIC. Poor completion rates for staff appraisals in 2020-21. Recent tensions between the trade union side and the management team, although relationships appeared to be improving at the time of our inspection
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89 The Senior Management Team (SMT) and a number of management posts below that had been occupied on a temporary promotion basis for over two years.
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90 Quality Indicators 8.1 The prison’s Equality and Diversity Strategy meets the legal requirements of all groups of prisoners, including those with protected characteristics. Staff understand and play an active role in implementing the Strategy. Rating: Poor COVID-19 and a reorganisation within the management team as a result of a medical retirement had impacted on efforts to promote and safeguard Equality and Diversity (E&D). The prison was able to talk about constructive partnership working developed in the past with Alzheimers Scotland, previous themed events in the prison and local training previously delivered on E&D, but action had paused completely during the pandemic and the prison was only just starting to re-engage with the agenda. At the time of the inspection the first meeting of a new operational E&D group had taken place, but no local E&D Strategy or Action Plan had been developed. Monthly meetings of the operational E&D group were planned, along with quarterly meetings with the Governor with a more strategic focus on E&D. The E&D Manager was only covering the role on a temporary basis resulting in the lack of a dedicated resource with appropriate specific training or experience around Equality & Diversity. The prison would benefit from conducting more systematic monitoring of data around opportunities for those with protected characteristics, and their involvement in disciplinary processes, relative to other prisoner groups to ensure no unintentional discrimination was occurring. Recommendation 41: HMP Shotts should prioritise re-energising the E&D agenda, including regular meetings of the E&D committee with prisoner representation, development of an E&D action plan, more systematic monitoring of data to avoid unintentional bias with employment, education and discipline, etc., and provide comprehensive training for the E&D Manager. 8.2 Appropriate action has been taken in response to recommendations of oversight and scrutiny authorities that have reported on the performance of the prison. Rating: Satisfactory The SPS and NHS prison healthcare teams were clear on the areas where performance improvements had to be prioritised after the previous HMIPS 2017 inspection report, and good progress had been made in several areas. Inspectors were pleased to see significant improvements had been achieved in relation to the range of educational opportunities and activities and development of the library. Inspectors also welcomed a notable improvement in mental health support since the last inspection.
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91 The prison conducted PRL audits on a systematic basis and there was also evidence of the prison responding to audit and assurance exercises carried out by SPS HQ. The reliability of some of the findings in these PRL audits might be questioned, however, as the one on E&D had provided substantial assurance, which did not tally with our own inspection. 8.3 The prison successfully implements plans to improve performance against these Standards, and the management team make regular and effective use of information to do so. Management give clear leadership and communicate the prison’s priorities effectively. Rating: Satisfactory The prison had a clear business plan based around five core themes of development, engagement, impact, standards and collaboration. Progress against the plan was carefully tracked and recorded, with clarity around which tasks had been completed and where slippage against the original envisaged timetable had occurred. Monthly business planning meetings provided a forum for discussing progress. Staff had been given the opportunity to input into the 2019/20 business planning process, but the pandemic had interfered with that process for systematic engagement. The prison intended to reinstate the engagement process for the next round of business planning. The GIC had recently started a series of engagement sessions with Unit Managers, who were encouraged to bring in some of their own direct reports for an open discussion on where and how improvement could be made. There was also a weekly meeting of FLMs every Monday and roster meetings every Wednesday. A brief was also emailed to all staff every month which provided an update on action in response to issues raised by staff. Despite these forums for engagement and communication, front line staff often criticised a lack of communication from management or what they perceived as late communication. Although this seemed to relate partly to changes in guidance around COVID-19 from Public Health Scotland, which the management team were obliged to implement without delay, there was evidence of the value of further strengthening communication with front line staff. We were concerned, however, that the Senior Management Team (SMT) and a number of management posts below that, had been occupied on a temporary promotion basis for over two years; this was not conducive to stability and longer term planning so we urge the SPS to secure some more permanent arrangements as soon as possible. Recommendation 42: The GIC should build on recent efforts to improve communications and engagement with staff, particularly with front line staff. Face-to-face discussions with larger groups of staff would be helpful.
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92 8.4 Staff are clear about the contribution they are expected to make to the priorities of the prison, and are trained to fulfil the requirements of their role. Succession and development training plans are in place. Rating: Generally acceptable Staff were clear about their roles and the contribution they were expected to make to the prison’s priorities, but regimes staff in particular found it hard having to cover for the absence of residential staff as it was more difficult for them to answer prisoners’ queries. Despite frustrations for some staff around being pulled away from their specialised functions, most staff expressed a strong commitment and motivation to their roles within the prison. Contingency plans for a range of potential issues were in place within the prison and there was regular and robust monitoring of anticipated vacancies and those expected to return to work to inform planned recruitment needs. Management also understood the issues they faced in managing succession issues within the prison. They were acutely aware, for instance, of the number of staff who were moving towards retirement age in the next few years and of the high number of individuals acting up at different levels within the organisation. They had plans in place to bring longer term stability to the staffing structure, but their planning was to some extent dependent on decisions elsewhere or national recruitment by SPS HQ. The prison had an overall record of 78% compliance for core competency training, with significantly lower compliance rates around Personal Protection Training, C&R, Fire Response Procedures and Emergency Response. Although still new to the post, the prison’s new Learning and Development Manager had a strong grip on these training priorities such as the need to focus on C&R training. COVID-19 restrictions during the pandemic had necessitated a lengthy pause in C&R training, and the prison estimated that it would take a year to recover due to limitations posed by the Training Variable and the challenges in securing staff availability. This was a concern, particularly in relation to the limited number of staff still in competency to conduct planned removals and other C&R processes. More positively the Learning and Development Manager was committed to embedding control and monitoring of training around the MyLo system, with the aim of ensuring that the principal responsibility for meeting training requirements rested more clearly with individuals and their line managers. Awareness raising and informal mentoring and shadowing opportunities to support those seeking promotion were in place, but a more structured approach might be beneficial. 8.5 Staff at all levels and in each functional staff group understand and respect the value of work undertaken by others. Rating: Generally acceptable The staffing challenges posed by COVID-19 related absences often required regimes staff to temporarily suspend their work parties and help their residential staff
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93 colleagues. Although it was difficult for regimes staff to fill in for residential staff, they accepted the need to do so and this helped facilitate recognition of respective roles and challenges. Front line SPS and NHS staff were required to work effectively together on a daily basis and again there was generally a respectful recognition of respective roles and shared challenges. The GIC and Deputy Governor took opportunities to rotate individuals into different roles to widen experience and support respect for the work of others. However, before the inspection there had been significant tensions in the relationship between the GIC and the local trade union representatives over a number of important issues which had clearly been difficult for all involved and which had contributed to some significant instability prior to our inspection. It was encouraging therefore to hear both the GIC and the trade union representatives suggest that relationships had started to improve, and we hope that continues. 8.6 Good performance at work is recognised by the prison in ways that are valued by staff. Effective steps are taken to remedy inappropriate behaviour or poor performance. Rating: Generally acceptable The prison had a robust but caring approach to managing staff absences, implementing return to work interviews and monitoring absences effectively. The total number of staff absences had reduced from 93 at Christmas 2021 to 27 at the time of our inspection, which was encouraging. The Staff Recognition Committee chaired by the HR Manager with representation from across the prison encouraged and discussed nominations for Governor awards. Individuals chosen by the Governor to receive such an award were given the choice on whether they wished to be presented with the award in front of their peers or preferred to receive the award in private. It was pleasing to see the Staff Recognition noticeboard refreshed with more recent photographs during the course of our inspection. A medal was presented to all staff reaching 20 years’ service and inspectors welcomed the establishment of an Achievement Tree with the names of those staff with 25 years’ service engraved on metal leaves. However, even recognising the exceptional additional challenges posed for the prison by the pandemic, it was disappointing to see that the completion rate for staff appraisals for 2020-21 was only 46%, despite evidence of reminders being sent. Inspectors hope that with COVID pressures now receding, management at all levels will now give the completion of staff appraisals the priority it deserves. Recommendation 43: HMP Shotts should give greater priority to the completion of staff appraisals, ensuring improved completion rates for 2021-22 and future years.
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94 8.7 The prison is effective in fostering supportive working relationships with other parts of the prison service and the wider justice system, including organisations working in partnership to support prisoners and provide services during custody or on release. Rating: Satisfactory The GIC contributed to the Criminal Justice Partnerships for North and South Lanarkshire and West Lothian, but Shotts acts as a national facility with prisoners often returning to a local prison prior to liberation; it simply wouldn’t be possible for the GIC to attend all community justice partnerships across the country. However, the prison worked alongside Police Scotland and MAPPA colleagues as required around public protection issues. It also supported the work of the Addictions Drugs Partnership for Lanarkshire, contributing specifically around drug related deaths and consideration of what more could be done within the prison and local community to reduce risks. At the time of the inspection the prison was exploring a range of initiatives to provide for those in their care such as Street Soccer and Street Cones. The prison hoped to bring the Metro Big Band to HMP Shotts, when they appeared at the Edinburgh Fringe, and to renew their previously successful partnership with Alzheimers Scotland to build on the work that had been suspended during COVID-19. A lot of these initiatives were at a very early stage at the time of our inspection, but it was encouraging to hear discussion of them as part of the planned recovery from COVID-19. 8.8 The prison is effective in communicating its work to the public and in maintaining constructive relationships with local and national media. Rating: Satisfactory As with other prisons, most media issues were dealt with by the national communications team within SPS HQ. However, the GIC had taken part in a recently aired BBC Scotland TV programme “My Kind of Town” partly to explain the importance of the prison within the local community. A local community group GBTS operated within the HMP Shotts Visitor Centre, and the prison management team appreciated the contribution they made to family visits and the successful running of themed events for prisoners and families.
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95 STANDARD 9 - HEALTH AND WELLBEING The prison takes all reasonable steps to ensure the health and wellbeing of all prisoners. All prisoners receive care and treatment which takes account of all relevant NHS standards, guidelines and evidence-based treatments. Healthcare professionals play an effective role in preventing harm associated with prison life and in promoting the health and wellbeing of all prisoners. Inspection Findings Overall rating: Poor In this standard, five quality indicators were rated as satisfactory, six were rated as generally acceptable and five were rated as poor, giving an overall rating of poor. This grading is reflective of the significant and sustained pressures on staff and the detrimental impact on patients receiving care. This is not a reflection of the considerable efforts made by staff within HMP Shotts or the North Lanarkshire Health and Social Care Partnership (HSCP) to support the healthcare needs of patients in HMP Shotts. There were 12 examples of good practice and 22 recommendations for improvement. The Healthcare Team had experienced significant and sustained staff shortages across all disciplines. Continued staff shortages had impacted on the team’s ability to provide adequate staffing and maintain a safe skill mix on some occasions. As described in the escalation below and in QI 9.2 and QI 9.6, there was no GP cover after 1.30pm. As a direct result of absences within the Senior Leadership team, staff reported they were not receiving one to one support or clinical supervision in any consistent pattern. Staff morale was low and staff were reporting fatigue. The fragility in the workforce was a significant concern and was escalated during the inspection. Senior managers were aware of the ongoing challenges for staff in HMP Shotts. Inspectors were provided with evidence of the service model review commissioned by senior management from North Lanarkshire HSCP. The lack of medical cover was impacting on the ability to provide long-term condition management of patients. All patients’ records are kept in the electronic Vision patient record system. It was not clear how staff were using the full function of this system effectively to collect data for patients with long-term health conditions. These factors have led to a systematic failure to deliver long-term condition reviews and oversight. The clinical pharmacy role was not patient facing and was not shown to be accessible for the population of HMP Shotts to discuss their medications with a member of the Pharmacy Team. This was not equitable to what is provided within the community in NHS Lanarkshire and is a concern. North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support as a matter of priority. It was not clear how the Pharmacy
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96 Team links to the NHS Lanarkshire Pharmacy Service for professional support and development. Our clinical partner’s discussion with the pharmacy adviser identified challenges with building effective working relationships with GPs to improve prescribing practices and the potential to develop multi-disciplinary team (MDT) working to improve patient outcomes. Registered nurses had the responsibility of reviewing complaints. There was no evidence as to whether staff had received training on how to review, respond and escalate complaints. Whilst staff had the opportunity to have informal discussions between themselves about complaints, there was no formal process in place to share learning from complaints. Inspectors were told that staff meetings were not taking place at the time of our inspection due to staffing shortages Inspectors were told that secondary care appointments were being sent by post because of issues with the IT systems in HMP Shotts, which presented a significant data risk. Inspectors were informed, during the inspection, that practice had changed and all referrals to secondary care were being managed electronically, directly to the NHS board, and postal referrals would be stopped. Inspectors will follow this up as part of their revisit. Escalation During the inspection, gaps were identified in senior clinical staffing resource during periods of the day, with no GP cover provided between 1:30 pm and 6pm. GP cover was provided in the health centre in the mornings and after 6pm, on-call GP facilities were available. This was highlighted during the previous inspection in 2017. Further to this, there were only two Band 5 Registered General Nurses (RGNs) on shift from 3:30pm until 6pm to undertake clinical duties, such as medication rounds and attend emergency calls (code red/code blue). Emerging concerns: The prison is open to activities during 3:30pm until 6pm and therefore there is an increased risk of incidents. There is no clear mechanism for the Band 5 RGNs to discuss concerns, or get support around clinical decision making for deteriorating patients during this period of time. Contacting the Scottish Ambulance Service for emergency response is the default position, as there is no other way to obtain measurable clinical advice. It was important to note that following a restructure and changes in both leadership and responsibility of prisoner healthcare. In response to North Lanarkshire’s HSCP identifying underlying challenges in healthcare delivery, a service model review of HMP Shotts was carried out in March 2022 and an action plan was developed. Inspectors reviewed both the service review and action plan provided and were encouraged to see many of the issues identified throughout the inspection and planned improvements. These had been assigned senior leadership, however were yet to have identified timelines. At the time of the inspection, we were not fully assured that all risks were being safely managed. Interim measures were needed to reduce potential risks, support staff and maintain the safety of the patients.
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97 We asked the Partnership to urgently review the service provision between 1.30pm and 6pm; identifying what clinical services and support is required to ensure the health needs of the prison population is equable with the community. We have escalated the above concerns internally within Healthcare Improvement Scotland and with the Clinical Service Manager for HMP Shotts and advised that we would be formally escalating these concerns to the North Lanarkshire Health & Social Care Partnership, NHS Chief Executive and SPS Chief Executive. These are outlined in QI 9.2, QI 9.6, QI 9.8 and QI 9.16. Primary care Patients could self-refer to healthcare services within the prison using a confidential self-referral system. Referral forms were available in the residential areas, with some in picture format. Self-referral forms were collected daily from a locked box by healthcare staff and then triaged to the appropriate service. GPs were available each day until 1:30pm in HMP Shotts. However, no medical cover was provided from 1.30pm to 6pm until the out of hours’ service became available at 6pm. The absence of medical cover during these times is a significant risk for patients and staff. Healthcare staffing was also reduced from 3:30pm. The variable levels of GP cover within the establishment was raised as a concern and were escalated during the inspection. Inspectors were told that patients would be seen by a GP within two weeks, or by a nurse within two days, depending on the medical need. After a patient was reviewed by nursing staff, inspectors observed the nurse record notes in the Vision system. Inspectors saw that a standard Situation background assessment recommendation (SBAR) approach to record keeping was generally used. However, the level of detail that was included varied. Mental Health There were processes in place on transfer to prison to identify patients requiring access to mental health services A referral system was open to all staff and self- referrals. Patients were triaged daily and followed up based on the level of urgency. At the time of inspection patients were waiting up to 6 weeks, urgent referrals could be seen within 72 hours if required. A multi-disciplinary meeting took place weekly between the Mental Health and Addictions Team discussing number of areas including; patients currently on Talk to Me, hospital referrals, upcoming liberations (including follow up arrangements), Care Programme Approach (CPA) plans for patients returning from hospital and waiting times for each discipline. There was evidence of liaison with Community Mental Health Teams (CMHT) pre-liberation and attendance at prisons suicide prevention strategy Talk to Me (TTM) case conferences. This was shared with primary care outside of mental health nursing hours. Psychiatry clinics took place regularly and urgent requests for consultations were responded to. Improvements were evident, since the last inspection, based on the introduction of standardised assessment tools which was not previously in place. However, North Lanarkshire HSCP should introduce an electronic system to record and update
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98 documents to keep documents live and ensure the most up to date information is accessible. There was no process in place for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. Substance misuse Individuals requiring support with drug and alcohol dependence were identified during their initial health assessment on transfer to the prison. A process was in place for patients who were receiving Opiate Substitution Therapy (OST) to continue their treatment upon transfer. Psychological support was available to patients in several forms. There was evidence of collaborative working and clear communication between SPS and the Addictions Team. This was through the multidisciplinary Substance Misuse Group which gave opportunities to discuss prisoners who may benefit from support from the Addictions Team. There was a discharge planning process in place to ensure continuity of care for those patients preparing for liberation. Harm reduction sessions were available to patients due to be liberated covering CPR training, overdose prevention and use of injectable naloxone. Person centred care plans are in place with evidence of patient involvement. However, there were some limitations in regards to patient choice of OST due to the HSCP awaiting allocation of funding. Senior management were following this up at the time of the inspection. Long-term conditions, palliative and end of life care Inspectors saw that admission screening identifies patients with long-term health conditions. However, it was not clear what follow up of long-term health conditions was in place or how this informed care planning. This is a significant concern. No long-term condition clinics or annual reviews were taking place at the time of inspection in HMP Shotts. A standardised national assessment tool, Supportive and Palliative Care Indicators Tool (SPICT) was in place in HMP Shotts to assess both palliative and end of life care needs. Palliative care, when required, was delivered in conjunction with both NHS and SPS. Development of Anticipatory Care Plans (ACPs) had been compromised by the pandemic and competing staffing priorities. However, continued work with St Andrews Hospice was identified as a priority for healthcare staff in HMP Shotts to continue to develop the work around ACPs and attendance at the Macmillan Palliative Care Team in custody group. All patients assessed on admission who had an identified life-limiting illness were added to the palliative care register and Anticipatory Care Plans (ACPs) were put in place. The electronically available ACPs were reviewed on an ongoing basis and were owned by the patient. Inspectors saw evidence of these for some patients with long-term conditions during the inspection.
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99 Infection, prevention and control All areas, where healthcare was delivered, were in a good state of repair and were clean and ready for use. During the inspection, inspectors found the clinical equipment was clean and ready for use and completed cleaning schedules were available for review. Inspectors saw evidence of a rolling programme of audits in place. Staff were knowledgeable regarding standard infection control precautions and had adequate supplies of PPE. The cleaning resource provided was sufficient and cleanliness was of a good standard. Encouraging observations Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. Where secondary care appointments were missed, the GP triaged these appointments so that the most clinically urgent were prioritised to be rescheduled. Healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. Prisoner information channel used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. Links with education department delivering heart health course and mental health stigma workshop. An emotional resource group facilitated by psychology was piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. At the request of SPS, psychology recently started facilitating drop in support sessions following adverse events within the prison. The sessions focus on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident or be emotionally impacted by an adverse event. A multidisciplinary substance misuse group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. Anti-bacterial hand sanitisers were available and a system in place to decontaminate the boxes used for personal belongings at security for visitors to HMP Shotts. A newsletter is produced from the daily huddles which would include any changes to guidance to be shared with staff. The daily huddle was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussions. In response to identification of underlying challenges in healthcare delivery a Service Model Review of HMP Shotts was carried out in March 2022 and an action plan was developed. HIS inspectors will look for evidence of implementation of this action plan in future inspections.
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100 Emerging concerns North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred. National co-ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at the prison during the prison’s core opening times or when nursing resource is available. North Lanarkshire HSCP must provide a room that is clean and clutter free at reception. North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected. North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in the patients VISON record. North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to - (i) ensure the risk to patients is reduced. (ii) support nursing staff in dealing with emergency situations. North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance. North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long-term conditions and that these are reviewed regularly. As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. NHS Lanarkshire’s pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts. North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time. NHS Lanarkshire HSCP should consider the reintroduction of the oral health educator role to support the dental service.
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101 NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain. NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. NHS Lanarkshire HSCP must ensure that alternative and consistent IT solutions are provided to support clinical staff as referrals by post is a significant data breach. North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff.
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102 Quality Indicators 9.1 An assessment of the individual’s immediate health and wellbeing is undertaken as part of the admission process to inform care planning. Rating: Generally acceptable performance HMP Shotts receives prisoners who are transferred from other prisons. All prisoners should receive a healthcare assessment by a nurse prior to being admitted into the prison. However, inspectors were told that some prisoners were not assessed until the following day due to staffing and workload pressures. During the inspection, inspectors observed the admission process. The immediate health and wellbeing needs of patients were identified on arrival by a registered nurse. Nursing staff used a standard health screening tool to carry out the process. Staff were observed to ensure the patient’s dignity and confidentiality was maintained throughout their health screening. Good systems and processes were in place to ensure that all the patient’s healthcare needs were identified during the screening assessment. These were documented in the Vision patient record system and shared with the appropriate Healthcare Teams. Inspectors were made aware that not all patients requiring psychiatry support intervention had been followed up. This is a concern. Inspectors were told work was being undertaken to develop a pathway to ensure early identification of patients requiring follow up. Inspectors will review the progress of this work. Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. This is good practice. Patients identified as requiring to see the GP are reviewed the following day. Medicines reconciliation takes place the following day by the GP and all drugs are prescribed onto the patient’s medication administration record (Kardex). Anyone identified as being at risk of self-harm or suicide is managed in line with the prison’s suicide prevention strategy; TTM. People coming into prison should be assessed for risk of self-harm. However, this system does not work when prisoners are transferred into HMP Shotts after 6pm. This is a significant concern for prisoners as there was no nursing cover provided after this time. During the inspection, inspectors were provided with details of the number of prisoners who had been admitted after 6pm during the period from May 2021 to May 2022. All prisoner transfers were facilitated by GEOAmey. While the room used for screening provided a confidential space, it was cluttered and had been identified in previous reports as being unfit for purpose. HMP Shotts must provide a room that is clean and clutter free to enable access to the hand washing facilities.
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103 Inspectors saw that systems and processes were in place to identify any patient unfit to be detained in prison, and appropriate actions were taken to maintain the safety of these patients. Recommendation 44: North Lanarkshire HSCP must ensure that all prisoners transferred to HMP Shotts are reviewed by a nurse before being admitted into the prison. Recommendation 45: North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred. Recommendation 46: National co-ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at the prison during the prison’s core opening times or when nursing resource is available. Recommendation 47: North Lanarkshire HSCP must provide a room that is clean and clutter free at reception. Good practice 12: Patients receive information at admission identifying services that are available to them regarding healthcare and how to refer to these services. 9.2 The individual’s healthcare needs are assessed and addressed throughout the individual’s stay in prison. Rating: Generally acceptable performance Following their initial health screening assessment, the patient’s medical history and prescribed medication was reviewed by a GP. The outcome of the assessment was recorded onto the patient’s Vision care record. Inspectors were told that, as part of the admission process, prisoners were provided with a pack that contained information about healthcare services available at HMP Shotts. Healthcare information was also displayed in the residential areas. Patients could self-refer to healthcare using a confidential self-referral system. Referral forms were available in the residential areas, with some in picture format. Self-referral forms were collected from a locked box by healthcare staff and then triaged to the appropriate service. Patients not seen in the residential areas that day, after having their referrals triaged, were given letters to let them know their appointment time. Inspectors were told that patients would be seen by a GP within two weeks, or by a nurse within two days, depending on the medical need. After a patient was reviewed by nursing staff, inspectors observed the nurse recorded notes in Vision. Inspectors saw that a standard SBAR approach to record keeping was generally used. However, the level of detail that was included varied. Inspectors saw that admission screening identifies patients with long-term health conditions. However, it was not clear what follow up of long-term health conditions was in place or how this informed care planning. This is a significant concern, as
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104 there was no process in place to provide follow up or review of long term health conditions in line with community provision. Near Me (a video calling system that allows patients to attend appointments remotely) was in place for secondary care appointments. Patients going out of prison to attend any external appointments were supported by GEOAmey. Where secondary care appointments were missed, the GP triaged these so that the most clinically urgent appointments were prioritised to be rescheduled. This is good practice. Inspectors were told that healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. This is good practice. Patients who missed their secondary care appointments were issued with a letter from the health centre to confirm the appointment would be rescheduled. Referrals to secondary care were in paper format and posted to the appropriate specialist service. This is a significant concern. Inspectors discussed the risks to patient confidentiality with this process with healthcare staff. During the inspection, the staff implemented a temporary process so that referrals will now be emailed securely and told inspectors that they will continue to look for more permanent solution. Inspectors were told that patients eligible for national screening programmes like bowel and abdominal aortic aneurysm screening would be supported to participate in these. However, inspectors could not find clear evidence in a patient’s Vision care record that this had happened. Patients who required social care to support them with their personal care needs, were provided access to this through an external care company. SPS can refer to this service and it was reported to be working well. There was also a clear process for healthcare staff to refer patients to occupational therapy, where assistive equipment was required to help support their care needs. Emergency equipment was in place and was found to be well maintained and organised. Emergency medication was found to be in date. Emergency equipment should be checked weekly. However, inspectors found that although equipment checks were being regularly carried out, this was not consistently recorded. Inspectors discussed this with staff to ensure that equipment checks are recorded consistently and evidence compliance with this. GPs were available each day until 1.30pm in HMP Shotts, however, no medical cover was provided from 1.30pm to 6pm until the out of hours’ service became available at 6pm. The absence of medical cover during these times is a significant risk for patients and staff. Healthcare staffing is also reduced from 3:30pm. Nursing staff told inspectors that this made them feel vulnerable and unsupported. The lack of medical cover in the afternoons was escalated at the time of the inspection to the Clinical Service Manager for HMP Shotts and advised that we would be formally escalating these concerns to the North Lanarkshire Health & Social Care Partnership, NHS Chief Executive and SPS Chief Executive.
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105 Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities. Recommendation 49: North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected Recommendation 50: North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in the patients VISON record. Recommendation 51: North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (iii) ensure the risk to patients is reduced. (iv) support nursing staff in dealing with emergency situations. Good Practice 13: Where secondary care appointments were missed, the GP triaged these appointments so that the most clinically urgent were prioritised to be rescheduled. Good Practice 14: Healthcare and SPS staff worked collaboratively to provide transport for these clinically urgent appointments with GEOAmey to support this. 9.3 Health improvement, health prevention and health promotion information and activities are available for everyone. Rating: Generally acceptable performance An opt-out Blood borne virus (BBV) screening programme was in place as part of the health screening process at the prison. Where patients had not received this screening at reception, they were able to opt-in to be screened through the healthcare self-referral form. Health promotion activity was in place in relation to infectious disease prevention. This included health education and health promotion programmes. However, it was not clear during the inspection what process was in place to ensure delivery of all national and local age appropriate health screening. Inspectors were told that screening appointment invitations were sent direct to patients but this could not be evidenced in a patient’s Vision care record. This was a concern. In the absence of a clear recording process, inspectors cannot be assured that patients are getting access to national screening and surveillance programmes.
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106 A wide variety of health education and health promotion information was available and displayed in patient areas, including the halls, health centre waiting room and visitors centre. Development work was in progress to ensure the leaflets and posters were available in a variety of formats making them accessible to a wide range of people. The information displayed included how to make informed decisions about health; including sexual health information and risks associated with drug use. Healthcare and prison staff worked together to deliver a programme of health promotion activities based on; health improvement, making better decisions and understanding the risks of behaviours and choices. The prisoner information channel was used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. This is good practice. The health improvement staff worked with the education department to deliver an 8-week heart health course and a mental health stigma workshop. This is good practice. Peer support was available through cocaine and alcoholics anonymous meetings. Details on how to attend these mutual aid meetings were displayed in the halls and patients would be signposted if they were engaged with the Addictions Team. All prisons in Scotland are non-smoking establishments. Vapes were made available to all prisoners in HMP Shotts. Information and support was also available on nicotine withdrawals and how to reduce or stop vaping. Those wanting to access sexual health services in the prison could do so by completing the healthcare self-referral form. Recommendation 53: North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance. Good Practice 15: Prisoner information channel used to share health promotion notices including a podcast with information on oral health, mental health support and a mindfulness group which was run by psychology. Good Practice 16: Links with education department delivering heart health course and mental health stigma workshop. 9.4 All stakeholders demonstrate commitment to addressing the health inequalities of prisoners. Rating: Satisfactory performance Healthcare staff described an understanding of health inequalities and were knowledgeable about the potential barriers to accessing care. Staff demonstrated a respectful and professional approach to all patients whilst maintaining confidentiality. They were supportive and gave explanations of care to be given whilst gaining consent. For example, at medication rounds staff took opportunities to support patients raising other healthcare concerns.
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107 We saw evidence that staff are directed to NHS Lanarkshire’s electronic learning platform where modules on equality and diversity are available. Staff spoken with were aware of the Equality Act 2010 and could sign post to where up to date policies were available on the staff intranet. Barriers to accessing care were identified at admission and staff facilitated any requirement to utilise interpreter services. 9.5 Everyone with a mental health condition has access to treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance A validated assessment tool was used to assess people referred to the Mental Health Team. This included an assessment of the patient's mental health, history, psychosocial factors, identification of risks, formulation of presenting problem and recommendation for care intervention. A risk assessment was completed for all patients at time of assessment and this was routinely updated every six months or in line with any significant changes in risk. Whilst the service used standardised tools for assessments and care plans, there was no electronic system in place. Having an electronic system would enable staff to record and update documents to keep them live and ensure the most up-to-date information was accessible. Patients were fully involved in their assessment, and had the opportunity to discuss the purpose and outcome of this assessment. The risks and benefits of any treatment or intervention offered were discussed with patients to allow them to make informed choices about their care. Individual person-centred outcome focussed care plans were written with the patient which reflected their goals. Patients had regular reviews where they were able to discuss and review their care. The multidisciplinary Mental Health Team consisted of health and social care professionals, including mental health nurses, psychologists and a consultant psychiatrist. There are challenges that NHS Lanarkshire are aware of and identified in the service review regarding the gaps in workforce. Due to the staffing pressures in the workforce, mainly in primary care, it meant that mental health nursing staff supported the wider healthcare team when required. Whilst psychology provided neuropsychological assessments there was no process in place to access specialists in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. The clinical lead for the team was a consultant psychiatrist, who chaired the weekly meetings where updates from each discipline were provided. Discussions took place about a number of areas including; patients currently on Talk to Me, hospital referrals, upcoming liberations (including follow up arrangements), Care Programme Approach (CPA) plans for patients returning from hospital and waiting times for each discipline. A wide range of therapies and treatments, appropriate for the patient population, were provided within the prison. The Mental Health Team’s operational guidelines
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108 details the procedure in place for working in partnership with services including; GP and physical health team, addiction service, social work, advocacy, chaplaincy, listener/peer support service and forensic psychology. The treatments and interventions offered to patients within the prison are equitable to those available in the community. The waiting times at the time of the inspection were acceptable and no longer than the national waiting times for these services. An emotional resource group, facilitated by psychology, had been piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. This is good practice. At the request of SPS, psychology have recently started facilitating drop in support sessions following adverse events within the prison. The sessions focussed on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident, or be emotionally impacted by an adverse event. This is good practice. Systems and processes were in place to ensure that any patient requiring inpatient mental health care is assessed and transferred to hospital under the Mental Health Care and Treatment (Scotland) Act 2003. Robust systems and processes were in place to ensure that patients requiring community follow-up on release from prison were referred to relevant services. This also included the provision of detailed discharge summaries. Recommendation 54: North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. Recommendation 55: North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. Good practice 17: An emotional resource group facilitated by psychology was piloted within the prison with positive feedback received. The group focussed on supporting prisoners to improve their awareness, recognition and regulation of difficult emotions. Good Practice 18: At the request of SPS, psychology recently started facilitating drop in support sessions following adverse events within the prison. The sessions focus on psychoeducation and signposting to services to provide support to those who may have witnessed a traumatic incident or be emotionally impacted by an adverse event.
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109 9.6 Everyone with a long-term health condition has access to treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Poor performance Inspectors were told that patients with a long-term condition were identified at their health screening during admission, through nurse triage or at medicine reconciliation. However, there was no formal process to ensure that patients were appointed for ongoing regular reviews. No long-term condition clinics or annual reviews were taking place in HMP Shotts at the time of inspection. Care plans were observed to be in place for some patients with associated risk assessments. However, the care plans were not person centred or outcome focussed and there was an inconsistent approach in regard to the implementation and review of the plans and risk assessments. Do not attempt cardiopulmonary resuscitation (DNACPR) forms were seen to be in place for two patients and these were generally well completed including the discussion with the patient. Inspectors were told of continued challenges with nursing staff resources and capacity this was observed during the inspection, as described in the escalation. The lack of medical cover was impacting on the ability to provide long term condition management of patients. All patient healthcare records are held in the Vision computer system. It was not clear how staff were using the full function of this system effectively to collect data for patients with long-term health conditions. These factors have led to a systematic failure to deliver long-term condition reviews and oversight. Nursing staff described links with community services for support and advice. For example, the tissue viability service and Diabetes service. This was working well to support patients. Recommendation 56: North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long-term conditions and that these are reviewed regularly. 9.7 Everyone who is dependent on drugs and/or alcohol receives treatment equitable to that available in the community, and is supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance Patients requiring support with drug and/or alcohol dependence were identified at health screening on transfer to the prison or as part of their health assessment appointments, using a validated screening tool. The outcome was documented in the patient care record. Patients were also sent a letter signposting them to support services available within the Addictions Team. As highlighted in QI 9.5 it is a concern that patient assessments are recorded on paper and scanned. The service should review IT options for patient assessments to be stored electronically allowing live documents (see recommendation in Q.I. 9.5).
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110 Systems and processes were in place to confirm prescriptions of those patients transferred to the prison. A copy of the Kardex was brought to HMP Shotts from the transferring prison for patient’s prescribed OST. Individual support needs for patients referred to addiction services were identified through an assessment process. Individual person-centred outcome-focussed care plans which reflected the support needs required, were in place for all patients. There was evidence of patient involvement in the writing of their care plans which were regularly reviewed, monitored and updated by the patient and their nurse or caseworker. Funding was due to be allocated for increasing the number of patients able to access Buvidal (long acting buprenorphine injections). Therefore, there were some limitations in terms of promoting patient choice for OST in line with the MAT standards at the time of the inspection. Senior managers were aware and liaising with the board to follow up the allocation of funding. Patients were provided with evidence-based pharmacological, harm reduction and psychological interventions. These interventions include psychosocial clinical interventions, relapse management and Cognitive Behaviour Therapy based psychoeducational work. A mindfulness group was available to prisoners, facilitated by an addictions caseworker delivering breath work, mindfulness and meditation. Systems and processes were in place to ensure that copies of patients’ medication prescription accompanied patients who were transferred to other prisons. This system was designed to ensure that there was no delay in continuing treatment once they arrived at the receiving prison. A standardised discharge planning tool was in place and ensured that patients were referred to community services and information was passed to these services for continuity of care. This included the early identification of community prescribers and pharmacies. All prisoners preparing for liberation were offered a harm reduction session that covered CPR training, overdose prevention and use of injectable naloxone use. The Addictions Team consisted of a range of multidisciplinary professionals including addictions nurses, case workers and a lead medical practitioner for addictions. The team worked closely with the Mental Health Team to allow for a range of treatments and therapies to be offered to patients. A multidisciplinary team meeting took place each week to discuss the allocation of referrals, and the assessments and reviews of patients. A medical practitioner for addictions is the clinical lead for the team. Written systems, protocols and procedures were in place to describe the joint working with mental health and primary care services for patients with co-morbidities. These included regular meetings with mental health nurses and/or primary care nurses according to the needs of the patients with co-morbidities. A multidisciplinary Substance Misuse Group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. This is good practice.
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111 Good Practice 19: A multidisciplinary substance misuse group has recently been restarted; the Addictions Team and SPS staff meet monthly to discuss any prisoners who may benefit from input from the Addictions Team. 9.8 There is a comprehensive medical and pharmacy service delivered by the service. Rating: Poor performance The Clinical Pharmacy Service delivered within HMP was provided by the national contract supplied by Lloyds Pharmacy. The current clinical pharmacy role involves the regular review of patient Kardexes and providing advice to other members of the multidisciplinary team. It also involves regular controlled drug checks (as part of the contract) but does not form part of a Clinical Pharmacy Service. The role was not patient facing and was not shown to be accessible for the population of HMP Shotts to discuss their medications with a member of the Pharmacy Team. This was not equitable to what is provided within the community in NHS Lanarkshire and is a concern. North Lanarkshire’s HSCP shared their service review as part of their evidence which contained specific recommendations about a Pharmacy Service. The service must action the recommendations regarding pharmacy provision and support as a matter of priority. NHS Lanarkshire provides HMP Shotts with pharmacy support for six hours per week to manage the Lloyds contract. During the discussions in relation to pharmacy, it was evident that pharmacy had not been part of the self-evaluation process. They described a lack of ability to influence within the service. Since the pandemic, they had been unable to attend the establishment due to a lack of available space. There was a lack of evidence to support multidisciplinary working in relation to medicines and the Pharmacy Service. The pharmacist described Standard Operating Procedures in place, which pharmacy had been involved in approving as part of the Home Office License Application. There was an up-to-date Home Office Licence in place at the time of our inspection. The pharmacist described the Prescribing Advisory Group (PAG) which prior to COVID-19 was well established, with a standing agenda and monitored prescribing as part of a multidisciplinary discussion. This was described to be in line with the current work within primary care which was positive. There are strong links with the National Prison Pharmacist Group and the pharmacist representing NHS Lanarkshire advised that there is regular communication with the service. This included updates on outcomes of these meetings via email, telephone calls and updates through the PAG (when this was operational). As the PAG has not been in existence since prior to the COVID-19 pandemic, it was unclear how the prescribing of medicines and the reviews of these have been managed during the pandemic. Inspectors spoke to staff providing Pharmacy Support Services and management was being provided by the Primary Healthcare Team. It was not clear of the wider
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112 links to the NHS Lanarkshire Pharmacy Service for professional support and development. The variable levels of GP cover within the establishment was raised as a concern and were escalated during the inspection. Discussions with pharmacy staff also identified challenges with building effective working relationships with GPs to improve prescribing practices and the potential to develop multi-disciplinary team working to improve patient outcomes. For example, the inspectors identified some inconsistencies and follow up when patients were on high dose antipsychotic medication. Inspectors were provided with the service review and acknowledged the recommendations in relation to medicine cover. During our inspection, inspectors reviewed the timings of medication administration. Some patients had supervised administration as not all patients are suitable for in possession medication. Inspectors saw that with the limitations in place due to the SPS regime, some patients were receiving their sedative medication early, between 3pm to 5pm. This was not therapeutic and was a significant concern. SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time. Nursing staff were observed administering medication and inspectors saw this was carried out safely. Paperwork in relation to medication administration was generally well completed. Concerns regarding nursing staff wearing radio earpieces during medication administration and the risk of medication errors was discussed with SPS staff during the inspection. This practice was changed during the inspection and staff were being accommodated to turn their radio’s off during medicine administration times. Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. Recommendation 58: NHS Lanarkshire’s pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts. Recommendation 59: North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time 9.9 Support and advice is provided to maintain and maximise individuals’ oral health. Rating: Generally acceptable performance Dental care was delivered in a clean and well-maintained environment. Dental procedures and management were carried out in line with national and NHS Lanarkshire guidelines.
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113 Patients were able to self-refer to the dental service and were given a letter to inform them of the date and time of their appointment or that they were on the waiting list. The dentist was available four days per week and managed their own waiting list, with a dental hygienist being available one day per week. Daily dental lists were managed to allow emergency treatments such as patients with pain to be seen as quickly as possible, usually the next day. The waiting time for other dental emergencies such as broken tooth was approximately two weeks. The waiting time for routine examinations was much longer. Inspectors were told that patients who required emergency dental care, or who were on treatment plans took priority over those requesting a routine examination. Inspectors saw the current waiting list that had 120 patients, the longest wait was from October 2020. Inspectors were told that the waiting list may not be completely accurate as some patients on it may have been seen more quickly, as an emergency or may have been released from prison. Inspectors were told that oversight and management of the dental waiting list was the responsibility of the Dental Team. The dental staff told inspectors that prior to the COVID-19 pandemic there were oral health educators who worked in the prison, who they considered a good resource. The oral health educators provided support directly to prisoners and could also be another source for the referral of patients to the dental service. Staff told inspectors that the reintroduction of oral health educators may reduce the number of patients on the waiting list. Clean and used dental instruments were stored appropriately, used and contaminated instruments were taken off site for decontamination. Recommendation 60: NHS Lanarkshire HSCP should consider the reintroduction of the oral health educator role to support the dental service. 9.10 All pregnant women, and those caring for babies and young children, receive care and support equitable to that available in the community, and are supported with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Not applicable There were no female prisoners in HMP Shotts at the time of the inspection. 9.11 Everyone with palliative care or end of life care needs can access treatment and support equitable to that in the community, and is supported throughout their stay in prison, on transfer and on release. Rating: Generally acceptable A standardised national assessment tool, (SPICT) was in place in HMP Shotts to assess both palliative and end of life care needs. Palliative care when required was delivered in conjunction with both NHS and SPS. Development of ACPs had been compromised by the pandemic and competing staffing priorities. However, continued work with St Andrews Hospice was identified as a priority for healthcare
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114 staff in HMP Shotts to continue to develop the work around ACPs and attendance at the Macmillan Palliative Care Team in custody group. Staff described how to access all necessary services, facilities and equipment services to deliver safe, effective, person-centred palliative or end of life care. There was evidence of a positive team-working relationship between the Prison Healthcare Team, NHS board palliative care service and community service. There was also strong links identified with Macmillan Palliative Care Team. Community Occupational Therapy services were accessed through the Community Rehab Team at University Hospital Wishaw if there was a requirement to assess patients for aids and adaptation. Staff described a prompt response. The accessible cells in HMP Shotts were of a good standard, they were spacious and well maintained. Prior to the pandemic any patients receiving palliative or end of life care were discussed by both SPS and NHS at a multidisciplinary meeting monthly. Staff were keen to reinstate this as a priority. 9.12 Everyone at risk of self-harm or suicide receives safe, effective and person centred treatment, and support with their wellbeing throughout their stay in prison, on transfer and on release. Rating: Satisfactory performance On transfer to the prison, every patient at risk of self-harm or suicide was assessed using a standardised and validated health screening tool, if the transfer took place before 6pm. As referenced in QI 9.1 there was no healthcare staff on duty from 6pm to complete risk assessments and follow the talk to me process. Any patient identified as being at risk of self-harm or suicide during their admission to prison or during their stay in prison were immediately commenced onto TTM. Inspectors reviewed several completed care plans and found them to be comprehensive and demonstrated patient involvement. This included the types of treatment being offered and were regularly reviewed. TTM case conferences were attended by the SPS and where possible a mental health nurse who was involved in the patients ongoing care. Mental health nursing cover was available Monday to Friday 8:30am to 3:30pm. Any case conferences taking place outside these times were attended by a primary care nurse. The Healthcare Team was aware of the importance of a registered mental health nurse (RMN) attending who knows the patient therefore tried to plan TTM around this. Patients were also encouraged and supported to participate in their own case conference. If a translator was required to support the patient this was booked in advance. All members of the wider Primary Care Nursing Team, involved in caring for patients had undergone TTM training. Evidence of a good multi-disciplinary Mental Health Team (MHT) was in place as discussed in QI 9.5. The clinical MDT discussed all patients who were in the SRU
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115 and being managed under Rule 41 (which relates to accommodation in specific conditions). There was a suicide prevention meeting with representatives from SPS and mental health nurses. Staff were able to arrange an urgent same day appointment with a mental health nurse for any patient who appeared to be at immediate risk of self-harm or suicide. Each stage of TTM process was clearly documented in the patient record on Vision. 9.13 All feedback, comments and complaints are managed in line with the respective local NHS Board policy. All complaints are recorded and responded to in a timely manner. Rating: Poor performance All complaints, comments and feedback were managed in line with the local NHS complaints policy. There was a clear governance structure in place for reporting and responding to complaints and feedback. Information posters describing the process were displayed in patient areas, including the halls and health centre waiting room. Feedback and comments forms and complaints forms were available in the halls, the patient waiting area in the health centre and on request from healthcare staff. These forms were clear and easy to understand in English however, the forms were not available in alternative formats and languages. Systems and processes were in place to record all complaints received in the health centre along with the date of receipt to ensure they were processed and responded to within set timescales. Systems and processes were in place to ensure that those making complaints would be acted on without negative consequences to current and future care or support. Registered nurses had the responsibility of reviewing complaints. There was no evidence if staff had received training on how to review, respond and escalate complaints. Whilst staff had the opportunity to have informal discussions about complaints there was no formal process in place to share learning from complaints. Inspectors were told that staff meetings were currently not taking place due to staffing shortages. It would be useful to hold weekly team meetings where learning from complaints can be disseminated with the wider Healthcare Team. Information was provided at the end of each complaint response informing patients of their right to contact the Scottish Public Services Ombudsman if they were not satisfied with the outcome or response to their complaint. Information about how to do this was also included.
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116 Recommendation 61: NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain. Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. Recommendation 63: NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. 9.14 All NHS staff demonstrate an understanding of the ethical, safety and procedural responsibilities involved in delivering healthcare in a prison setting. Rating: Poor performance Staff had a clear understanding of their roles and responsibilities in reporting any situations which could result in physical or psychological harm to those in prison. Healthcare staff indicated that any issues requiring to be raised as a priority were recorded on a SPS intelligence report. All registered staff were aware of their legal obligations for confidentiality and keeping accurate and prompt records, as part of maintaining their registration and commitment to the Nursing and Midwifery Council (NMC) code. All staff had their own access to the electronic record keeping system Vision clinical system. As part of prison healthcare staff induction, staff were informed how to report any concerns. Inspectors were told that secondary care appointments were being sent by post because of issues with the IT systems in HMP Shotts, this is a significant data risk. Inspectors were made aware during the inspection that practice had changed and all referrals to secondary care were being managed electronically directly to the NHS board and postal referrals would be stopped. Inspectors will follow this up as part of their revisit. Recommendation 64: NHS Lanarkshire HSCP must ensure that alternative and consistent IT solutions are provided to support clinical staff as referrals by post is a significant data breach. 9.15 The prison implements national standards and guidance, and local NHS Board policies for infection prevention and control. Rating: Satisfactory performance Inspectors observed good infection control precautions in place at HMP Shotts. PPE was available with hand sanitiser and both clinical and domestic waste bins were available for disposal. Visitors were sign posted to use masks on arrival and to dispose of when leaving. At reception, visitors were prompted sanitising the boxes used for personal belongings, this is good practice.
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117 The healthcare centre facility and clinical rooms within HMP Shotts were of a good standard and were visibly fresh and clean, the fabric was intact and could be effectively decontaminated. Inspectors saw areas in the halls where healthcare staff administer medicines and triage, these were of a good standard and were clean and ready for use. Inspectors saw evidence of daily cleaning schedules with senior nurse oversight and sign off. HMP Shotts used an electronic system to upload audits including standard infection control audits. These were reviewed for compliance by senior staff and results were shared through staff safety briefs for any non-compliance actions plans to be completed. These were also shared at the North Hygiene meetings represented by senior management. Healthcare staff had standard infection audit programme in place which included other aspects of healthcare delivery and compliance. Cleaning resource was provided by a private contractor supplied by SPS. The cleaning was of a good standard and staff reported no concerns with provision. Trained pass men were responsible for cleaning in residential areas and were visible throughout the inspection. The standard of cleanliness in HMP Shotts was high. The health centre is also externally audited by NHS Lanarkshire. Inspectors observed the most recent audit carried out. This had identified some areas for improvement that staff had acted upon. Equipment was clean and ready for use and staff were knowledgeable about standard infection control precautions (SICPs). Inspectors observed good hand hygiene practice from staff. Healthcare staff could sign post inspectors to the National Infection Prevention and Control Manual (NIPCM) through NHS Lanarkshire intranet platform. Inspectors saw infection prevention control was part of staff mandatory training requirements. Staff had been fitted for FFP3 masks during the pandemic, these were available in emergency bags. PPE was readily available in clinical areas and staff were wearing masks. Inspectors saw some variable compliance with mask wearing from SPS officers, this was raised at the time of the inspection. Changes to guidance was discussed at the morning adult services huddle. A newsletter was produced from these meetings which would include any changes to guidance to be shared with staff. This is good practice. Good Practice 20: Anti-bacterial hand sanitisers were available and a system in place to decontaminate the boxes used for personal belongings at security for visitors to HMP Shotts. Good Practice 21: A newsletter is produced from the daily huddles which would include any changes to guidance to be shared with staff.
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118 9.16 The prison healthcare leadership team is proactive in workforce planning and management. Staff feel supported to deliver safe, effective, and person-centred care. Rating: Poor performance HMP Shotts Healthcare team had experienced significant and sustained staff shortages across all disciplines. Continued staff shortages had impacted on the team ability to provide adequate staffing and maintain a safe skill mix on some occasions. During the inspection there were further absences in the Senior Leadership team for both primary care and mental health services. Nursing staff numbers were further reduced to 2 primary care nurses at 3.30pm when other members of the multidisciplinary team shift ended. From 3.30pm to 6pm their role was to provide healthcare delivery which included responding to emergencies, admitting prisoners being transferred from other prisons and delivering medications. As described in the escalation and in QI 9.2 there was no GP cover after 1.30pm. As a direct result of absences within the Senior Leadership team, staff reported they were not receiving one to one support or clinical supervision in any consistent pattern. Staff morale was low and staff were reporting fatigue. The fragility in the workforce was a significant concern and was escalated during the inspection. There was no consistent senior leadership structure in place to support staff in the absence of medical cover. Inspectors found all staff to be open and honest about the challenges in HMP Shotts. Senior managers were aware of the ongoing challenges for staff in HMP Shotts. Inspectors were provided with evidence of the service model review commissioned by senior management from North Lanarkshire HSCP. In response to the identified challenges during a change in leadership accountability for HMP Shotts prior to the inspection including a workforce review. This had identified key areas of improvement and actions which illustrated the significant concerns raised by inspectors however inspectors raised concerns regarding the staffing provision both nursing and GP’s, the impact on staff and the impact on patients because of the lack of provision. There was a commitment to review workforce and seek solutions to provide additional staff and senior oversight in HMP Shotts with a continued recruitment. This would allow a re-introduction of clinical supervision and one to one support for staff. Inspectors will follow up the progress of this work with HMP Shotts following the escalation response and will return to HMP Shotts to review progress. There was a mandatory training programme in place which was overseen by senior management. All staff in HMP Shotts had received an induction programme. Inspectors participated in the daily huddle which was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussion. This is good practice. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff.
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119 Good Practice 22: The daily huddle was used as a mechanism to RAG rate staffing insufficiencies and seek solutions amongst other patient centred discussions. 9.17 There is a commitment from the NHS Board to the delivery of safe, effective and person-centred care which ensures a culture of continuous improvement. Rating: Generally acceptable performance HMP Shotts Prisoner Healthcare Team was managed by the Adult Health Services Unit (AHSU) within North Lanarkshire Health & Social Care Partnership (HSCP). A restructure of the North Lanarkshire HCSP took place over a year ago resulting in changes in both leadership and responsibility of Prisoner Healthcare Team. In response to identification of underlying challenges in healthcare delivery a service model review of HMP Shotts was carried out in March 2022 and an action plan was developed, this is good practice. Inspectors reviewed both the service review and action plan provided and were encouraged to see identification of many planned improvements. These had been assigned senior leadership and yet to have identified timelines. Inspectors will follow up and review the progress of this work. Operational healthcare staff within the prison were aware of the HSCP Leadership structure and their roles and responsibilities for the ongoing service delivery of healthcare within the prison. There had been changes in leadership in this structure in the last year. Nursing staff could describe the leadership structure but were not familiar with some of the senior management that were present during the inspection. Senior managers from the North Lanarkshire HSCP were visible in the health centre during the inspection but did not routinely base themselves in HMP Shotts. Inspectors were provided with evidence that prisoner healthcare is represented at all appropriate NHS Lanarkshire primary care forums. There was leadership and representation of prisoner healthcare services across the Operational, Governance and Professional Senior Manager Team forums. Where patients had concerns about healthcare delivery, they were encouraged to report these using the complaints forms available in the residential areas. The service review had also highlighted plans to improve service delivery by conducting surveys and questionnaires for patients led by health improvement colleagues. Prison healthcare uses the DATIX system to report any adverse events in NHS Lanarkshire. Reports from this were visible to managers within the HSCP and were discussed at clinical governance committee meetings. Inspectors were provided with minutes of this meeting and saw DATIX relating to prisoner healthcare being discussed. Staff told inspectors there was inconsistency in reporting due to staff shortages. Any learning from DATIX incidents was shared with staff verbally as well as by email.
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120 Good Practice 23: In response to identification of underlying challenges in healthcare delivery a Service Model Review of HMP Shotts was carried out in March 2022 and an action plan was developed. HIS inspectors will look for evidence of implementation of this action plan in future inspections.
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121 Annex A Summary of Recommendations To be updated after matters of fact stage
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122 Annex B Summary of Good Practice To be updated after matters of fact stage
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123 Annex C SUMMARY OF RATINGS Standard/QI Standard rating/QI rating Standard 1 – Lawful and Transparent Custody Satisfactory QI 1.1 Satisfactory QI 1.2 Satisfactory QI 1.3 Satisfactory QI 1.4 Satisfactory QI 1.5 Satisfactory QI 1.6 N/A QI 1.7 Satisfactory QI 1.8 Generally acceptable QI 1.9 Satisfactory Standard 2 – Decency Generally acceptable QI 2.1 Satisfactory QI 2.2 Satisfactory QI 2.3 Generally acceptable QI 2.4 Satisfactory QI 2.5 Satisfactory QI 2.6 Poor Standard 3 – Personal Safety Generally acceptable QI 3.1 Generally acceptable QI 3.2 Good QI 3.3 Generally acceptable QI 3.4 Generally acceptable QI 3.5 Satisfactory QI 3.6 Generally acceptable QI 3.7 Satisfactory Standard 4 – Effective, Courteous and Humane Exercise of Authority Satisfactory QI 4.1 Generally acceptable QI 4.2 Generally acceptable QI 4.3 Satisfactory QI 4.4 Satisfactory QI 4.5 Generally acceptable QI 4.6 Satisfactory QI 4.7 Satisfactory QI 4.8 Satisfactory QI 4.9 Satisfactory QI 4.10 Good
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124 Standard 5 – Respect, Autonomy and Satisfactory Protection Against Mistreatment QI 5.1 Satisfactory QI 5.2 Satisfactory QI 5.3 Good QI 5.4 Satisfactory QI 5.5 Satisfactory QI 5.6 Satisfactory QI 5.7 Satisfactory QI 5.8 Satisfactory Standard 6 – Purposeful Activity Generally acceptable QI 6.1 Generally acceptable QI 6.2 Generally acceptable QI 6.3 Generally acceptable QI 6.4 Generally acceptable QI 6.5 Good QI 6.6 Generally acceptable QI 6.7 Satisfactory QI 6.8 Satisfactory QI 6.9 Generally acceptable QI 6.10 Satisfactory QI 6.11 Good QI 6.12 Good QI 6.13 Satisfactory QI 6.14 Generally acceptable QI 6.15 Good Standard 7 – Transitions from Custody into the Community Generally acceptable QI 7.1 Generally acceptable QI 7.2 Satisfactory QI 7.3 Satisfactory QI 7.4 Generally acceptable QI 7.5 Generally acceptable Standard 8 – Organisational Effectiveness Generally acceptable QI 8.1 Poor QI 8.2 Satisfactory QI 8.3 Satisfactory QI 8.4 Generally acceptable QI 8.5 Generally acceptable QI 8.6 Generally acceptable QI 8.7 Satisfactory QI 8.8 Satisfactory Standard 9 – Health and Wellbeing Poor QI 9.1 Generally acceptable QI 9.2 Generally acceptable QI 9.3 Generally acceptable
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125 QI 9.4 Satisfactory QI 9.5 Satisfactory QI 9.6 Poor QI 9.7 Satisfactory QI 9.8 Poor QI 9.9 Generally acceptable QI 9.10 N/A QI 9.11 Generally acceptable QI 9.12 Satisfactory QI 9.13 Poor QI 9.14 Poor QI 9.15 Satisfactory QI 9.16 Poor QI 9.17 Generally acceptable
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126 Annex D Prison Population Profile on [ADD DATE]
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127 Annex E Inspection Team Wendy Sinclair-Gieben, HMIPS Stephen Sandham, HMIPS Calum McCarthy, HMIPS Kerry Love, HMIPS Sam Gluckstein, HMIPS Billy Menzies, Serco Paul Durning, SPS John Shanks, Scottish Prison Service Margaret Rose Livingstone, Education Scotland Ann Kivlin, Education Scotland Sheila Brown, Education Scotland Neil Gentleman, Care Inspectorate James Black, Care Inspectorate Catherine Haley, HIS Lindsay Macphee, HIS Jamie Thomson, HIS Sophie Moss, HIS
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128 Annex F Acronyms used in this Report ABS Anti-Bullying Strategy ACP Anticipatory Care Plan AHSU Adult Health Services Unit BBV Blood Borne Virus BICS British Institute of Cleaning Science BSL British sign language CAST Custody Adjustment Support and Transition CBSW Community Based Social Workers CIP Community Integration Plan CMHT Community Mental Health Team C&R Control and Restraint CCTV Closed Circuit Television COPFS Crown Office and Procurator Fiscal Service COVID-19 Corona Virus Disease 2019 CPA Care Programme Approach CPR Cardiopulmonary resuscitation CPT European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment DATIX NHS electronic incident reporting system DNACPR Do not attempt cardiopulmonary resuscitation ECR Electronic Control Room ECHR European Convention of Human Rights E&D Equality and Diversity EDF Equality and Diversity Form ESOL English to Speakers of Other Languages FCO Family Contact Officer FLM First Line Manager GBTS Getting Better Together Shotts GIC Governor in Charge GPAs General Programme Assessments H&S Health and Safety
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129 HIS Healthcare Improvement Scotland HMCIPS Her Majesty’s Chief Inspector of Prisons for Scotland HMIPS Her Majesty’s Inspectorate of Prisons for Scotland HMP Her Majesty’s Prison HQ Headquarters HSCP Health and Social Care Partnership ICC Internal Complaints Committee ICM Integrated Case Management IMU Intelligence Management Unit IPM Independent Prison Monitor LCM Learning Centre Manager LIM Local Incident Management LS/CMI Level of Service/Case Management Inventory LTPs Long Term Prisoners MAPPA Multi-Agency Public Protection Arrangements MDT Multi-Disciplinary Team MHT Mental Health Team MORS Management of an Offender at Risk from Any Substance NIC National Induction Centre NIP National Induction Presentation NIPCM National Infection Prevention and Control Manual NMC Nursing Midwifery Council NOC Notification of Concern NPM National Preventive Mechanism NTE National Top End OPCAT UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment OLR Order of Lifelong Restriction OST Opiate Substitution Therapy PAG Prescribing Advisory Group PANEL Participation, Accountability, Non Discrimination and Equality, Empowerment, Legality PBSW Prison Based Social Work PCF Prisoner Complaint Form
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130 PCF1 Prisoner Complaint Form 1 PCF2 Prisoner Complaint Form 2 PCMB Programme Case Management Board PEI Physical Education Instructor PEEP Personal Emergency Evacuation Plans PER Prisoner Escort Record PIAC Prisoner Information Action Committee PIC Prisoner Information Channel PMAG Prison Monitoring and Assurance Group POs Personal Officers PPE Personal Protective Equipment PPT Personal Protection Training PR2 SPS Prison Records System (version 2) PRL Prison Resource Library PTI Personal Training Instructor RAG Red, Amber, Green RGNs Registered General Nurses RMN Registered Mental Health Nurse RMT Risk Management Team RRA Reception Risk Assessment SBAR Situation Background Assessment Recommendation SBR Suspected Bullying Report SEB Shotts Employability Board SICP Standard infection control precaution SMT Senior Management Team SOP Standard Operating Procedure SPICT Supportive and Palliative Care Indicators Tool SPS Scottish Prison Service SPSO Scottish Public Service Ombudsman SRU Separation and Reintegration Unit SSM Special Security Measure SSOW Safe Systems of Work TTCG Tactical Tasking and Co-Ordination Group TTM Talk To Me
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131 UOF Use of Force VIR Violent Incident Review VRG Violence Reduction Group
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Total Recommendations ‐ 22 Total Open Actions ‐ 16 Priority Open Actions – 6 Closed Actions – 6 Appendix 1‐ HIS Review Recommendations Update 17th May 2023 HIS Priority Actions RAG Update Recommendation 44: North Lanarkshire HSCP and the SPS should work jointly to ensure that transfer arrangements for incoming prisoners are such that they enable a nurse to review/TTM assess all prisoners before they are admitted to a prison A Discussions have taken place with SPS Senior Management on site with an agreement where possible to arrange transfers of prisoners into the establishment prior to the completion of healthcare staff shifts. This is being monitored, and any deviation (i.e. where a prisoner arrives after healthcare staff have finished) will be managed as agreed with the Governor in Charge (GIC). Prisoner assessed by SPS staff and placed on observation until Healthcare staff can assess. Clinical Manager/Team Lead will continuously review compliance with requirement for admissions Healthcare screening, and any deviation will be escalated via the Datix system and highlighted on safety brief, with immediate action to assess prisoner as soon as is possible CNM review current process for admissions to ensure this is completed for all prisoners on transfer into to HMP Shotts. Data Collection started 1st May – daily number of transfers/time of transfer/daily number assessed by Primary Care Team (PCT) /daily number not assessed on the day. NB: There have been no prisoner transfers since 1st May 2023 Recommendation 48: North Lanarkshire HSCP must revise without delay, the process in place when identifying long term health conditions and provide assurance that patients are reviewed in line with what is equitable in the community to address health inequalities A Team Meeting held to discuss staff development and responsibility for chronic disease management. CNM delegated with assigning specialist areas to staff and researching training opportunities. Review current process to identify long term conditions for all prisoners on admission to the prison as well as any changes in their condition that may develop. Process to be devised to ensure prisoners with long term conditions are reviewed in line with community guidance and this is clearly documented within patients notes. All prisoners with a long term condition will have a person centred care plan and appropriate risk assessment completed. These should be reviewed and updated regularly.
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Recommendation 52: North Lanarkshire HSCP as a matter of urgency must review the medical cover available in the afternoons to: (i) ensure the risk to patients is reduced (ii) support nursing staff in dealing with emergency situations A The mechanism in place (staff contact the Flow Navigation Centre in afternoon hours with concerns about patients) was reviewed, updated and re‐circulated to staff following the inspection. Consultant connect is available as an integral part of this but has seldom been used or required. The Local Enhanced Service (LES) specification has been developed with invitations to tender being sent to all GPs in NHSL. 1 practice responded and met with the General Manager, Associate Medical Director and Clinical Director. 1 GP is currently shadowing for greater contextual understanding of the role. Associate Medical Director, Clinical Director and General Manager are also working on a contingency if this option does not result in an approved LES. Recommendation 57: As a priority North Lanarkshire’s HSCP must action the recommendations made in their service review regarding pharmacy provision and support to provide a service equitable with the community. A Prescribing processes and checks have been reviewed and checks are made regularly for accuracy and safe prescribing. Review of Pharmacy admin staff roles will form part of a wider workforce review. The existing staff who work in the pharmacy roles are supported by a senior Pharmacy Advisor from NHS Lanarkshire who visits regularly and is integrated into appropriate forums etc. in the delivery of service. The National Pharmacy Contract also provided senior pharmacist support on a weekly basis in the form of a site based day. The implementation of the new national pharmacy contract has been agreed. Lloyds will cease their contract on 30th June 2023. MD Green have been awarded the new contract. Weekly national meetings are in place to project plan the changeover. ECOR is being progressed to recruit to pharmacy vacancy. Recommendation 61: NHS Lanarkshire HSCP and SPS must ensure complaints forms are available in alternative formats and languages to ensure all patients can provide feedback, raise concerns and complain G The 12 most utilised languages complaint forms have been developed. Discussions to take place with SPS Head of Offender Outcomes to ascertain and agree the process for implementing these to prisoners as and when required. Meeting arranged 17th May 2023. Recommendation 65: North Lanarkshire HSCP must demonstrate implementation of recommendations from service review and provide clear pathways to support staff on site in HMP Shotts in the absence of senior staff A There has been prolific senior management presence onsite since November 2022. Recruitment of the CNM for PCT has been successful with a start date of 3rd July. Senior management support continues to be provided until the CNM starts. The Improvement Manager has been in post since the 3rd April, is onsite most days and has well integrated links to the senior management team.
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HIS Non Priority Actions RAG Update Recommendation 46: National co‐ordination and discussion with partner agencies (such as Police Scotland, Scottish Courts, GEOAmey and SPS) is required to ensure that people arrive at prison during the prisons core opening times or when nursing resource is available A Discussion has taken place with SPS Senior Management on site, with an agreement where possible to arrange transfers of prisoners into the establishment prior to the completion of healthcare staff shifts. This is being monitored, and any deviation (i.e. where a prisoner arrives after healthcare staff have finished) will be managed as agreed with the GIC ‐ Prisoner assessed by SPS staff and placed on observation until Healthcare staff can assess. CNM will continuously review compliance with requirement for admissions Healthcare screening and any deviation will be escalated via the Datix system and highlighted on safety brief, with immediate action to assess the prisoner as soon as is possible. Compliance monitoring and data collection has begun since 1st May now the IM has started post however there have been no prisoner transfers since 1st May 2023 due to issues with GEOAmey Recommendation 56: North Lanarkshire HSCP must ensure that person centred care plans and appropriate risk assessments are in place for all patients with long term conditions (LTC) and that these are reviewed regularly A A structure to identify and review patients with LTC has been developed and thereafter medical reviews will occur as result of this structure with a recall system in place on VISION. Frequency of reviews will be decided by medical staff based on need and any relevant guidelines. When staffing allows; allocation of responsibility for chronic disease management will be conducted based on individual staff member’s skills, experiences and development needs. Senior Nurse will via staff PDP identify these responsibilities and assess issues such as training opportunities required
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HIS Non Priority Actions RAG Update Recommendation 45: North Lanarkshire HSCP must develop a pathway to ensure patients receive psychiatry follow up when transferred, G Link with the head/lead forensic psychiatrists Scottish Prisons and Community at all health boards to devise a simple pathway to share that says a transfer letter from previous prison must be sent to SHOTTS pre admission to allow appropriate follow up appointment to be booked with psychiatrist. To mitigate in the short term, the mental health secretary will check vison/docman for every new prisoner transfer to ascertain if psychiatry follow‐up is required for them. If it is the patient will be booked to our psychiatrist as per instructions of their last psychiatric letter. Recommendation 54: North Lanarkshire HSCP must introduce an electronic system to record and update documents to keep documents live and ensure the most up‐to‐date information is accessible. A On an ongoing basis, there will be scoping of whether North HSCP can introduce an electronic system to record and update documents to keep documents live and ensure the most up to date information is accessible. Discussion has been ongoing regarding the potential introduction of the MORSE system At present a national, (and older) version of Vision is the main system in use across all HMPs in Scotland Recommendation 55: North Lanarkshire HSCP must develop a pathway for accessing specialist support in intellectual disabilities, autistic spectrum disorder, neuropsychiatric disorders and cognitive impairment. A The service has no bespoke internal functionality for these disorders based at the prison, but any individual with such presenting needs would be referred to the existing Lanarkshire services. This entails prisoner patients having to wait an equitable period of time as the general public for assessment and any interventions that such a referral may produce. Newly established ‘Lanarkshire’ pathways are in situ for ADHD and Cognitive Impairment. There has been change in personnel in relation to the Senior Nursing position for Mental Health & LD. New staff are establishing themselves now and will support with the further development of access for prisoner patients to appropriate services. Recommendation 58: NHS Lanarkshire's pharmacy service must provide structured and regular support to staff involved in supporting pharmacy services within HMP Shotts A Review of Pharmacy admin staff roles will form part of a wider workforce review when the newly appointed Project/Improvement Manager is in post. However, the existing staff who work in the pharmacy roles are supported by a senior Pharmacy Advisor from NHS Lanarkshire who visits regularly and is integrated into appropriate forums etc. in the delivery of service. The implementation of the new national pharmacy contract has been agreed. Lloyds will cease their contract on 30th June 2023. MD Green have been awarded the new contract. Weekly national meetings are in place to project plan the changeover. ECOR is being progressed to recruit to pharmacy vacancy.
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HIS Non Priority Actions RAG Update Recommendation 59: North Lanarkshire HSCP and SPS must seek solutions to assist staff to administer medication at a suitable and therapeutic time A Existing practices are made as safe as possible (SOP’s in place) by working in conjunction with SPS. Development is planned between both organisations to change the administration of “Weekly” medication as and when healthcare staffing enables this. Recommendation 50: North Lanarkshire HSCP must ensure that all eligible patients who wish to be involved in national screening programmes are supported to do so and that this is clearly documented in patients VISION record A The service will ensure on an ongoing basis that prisoners are able to be included in national screening programmes for Bowel cancer and AAA (If in the appropriate age groups). Currently prisoners receive their own screening appointment letters directly (not via healthcare department). This is reliant on their whereabouts being known. A National solution is required for this and NHS Lanarkshire will keenly participate. If this process is required to be evidenced/audited, a system must be developed to ensure that all appropriate patients have accessed screening by direct correspondence and that this is documented on Vision. This will require prisoners to share these details. Recommendation 53: North Lanarkshire HSCP must ensure that patients are able to access national screening programmes in line with community provision and keep accurate records of attendance A As above Recommendation 60: NHS Lanarkshire HSCP should consider the re‐introduction of the oral health educator role to support the dental service G Oral health care team are updating PPT training with SPS on 22nd February 23 and will commence monthly education visits once training completed in March. Service lead anticipates more frequent visits in future plans. IM is meeting senior health improvement manager 17th May to discuss position and move forward
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HIS Closed Actions RAG Update Recommendation 47: HMP Shotts must provide a room that is clean and clutter‐free at reception G Interview/Assessment room in Reception area has been reviewed, has been cleared, is regularly cleaned and is now fit for purpose. Recommendation 49: North Lanarkshire HSCP must implement a system for secondary care referrals that ensures patient confidentiality is protected G Immediately after the inspection a solution was found with use of secure e mail over surface mail as SCI Gateway option was still being explored. SCI gateway infrastructure is now in place and went live on 11th May 2023. Recommendation 51: North Lanarkshire HSCP must ensure that checks on emergency equipment are carried out within the agreed timeframe and that these checks are clearly recorded. G Emergency equipment is checked regularly and documentation is signed to evidence this by healthcare staff. CNM will complete random audits of documentation to ensure compliance. Recommendation 62: NHS Lanarkshire HSCP must ensure that all staff managing complaints receive training to ensure that all complaints are correctly managed. G The senior management team have reviewed all processes which now ensures the CNM onsite manages all Stage 1 complaints. Full training has been issued. Anything Stage 2 and above is escalated and managed via the organisational process (Patient Affairs & General Manager). Recommendation 63: NHS Lanarkshire HSCP should develop a process to discuss complaints to share learning and identify any themes or required improvements. G CNM has reintroduce monthly team meetings. CNM to chair with attendance from SM/SN to provide additional info and communication from strategy group and operational issues. Standing Agenda items are agreed with opportunity to add additional items. Items to include Infection Prevention & Control, Briefing Notes, Datix's, Actions Plans & shared Learnings. Discussion, Action points and updates to be recorded in R Drive. Recommendation 64: NHS Lanarkshire HSCP must ensure that alternative and consistent IT G Immediately after the inspection a solution was found with use of secure e mail over surface mail as SCI Gateway option was still being explored. SCI gateway infrastructure is now in place and went live on 11th May 2023.
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solutions are provided to support clinical staff as referrals by post is a significant data breach
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Total Recommendations ‐ 32 Total Open Actions – 10 Total Closed Actions ‐ 22 Appendix 2 ‐Service Model Review Update 17th May 2023 Service Model Review Actions RAG Update Recruitment and retention of staff A Ongoing Open Day's planned 6‐8 monthly with SPS. Held on 2 occasions (Oct 2022 & Feb 2023). Shadow shift project to engage with Lanarkshire Staffbank staff and promote experience in Shotts and allow for training of temporary staff. Rolling adverts for Primary Care staff via national SHOW vacancy website. Attendance by Practice Education Facilitators to Open Day and regular communication to facilitate Student/Mentorship in prison setting once vacancy backfill allows for clinical supervision of students. Recruitment is on‐going. Application made to STAC for Secure Environment Allowance for staff. Awaiting decision. Clearly define roles and responsibilities for each grade of staff and identify development opportunities A Newly appointed seconded Team Leader/Clinical Nurse Manager (CNM) in post April 23 ‐ gaining access to systems presently. 2nd CNM appointed with a start date of July 23. Develop monthly service development meetings with the MDT G Improvement manager will set up monthly improvement group meetings with the senior team and teams within the HC. The first meeting is set for 24th May within the HC. A staff experience questionnaire has been sent to all staff for completion. Results will be presented at the meeting. Student Feedback A Practice Education Facilitator for Shotts has changed early 2023 and we are engaged with team to facilitate training for current and future Primary Care team staff to bring suitable students into the learning environment. Currently we need more registrants in the team to support student plans. Completion of Mandatory and Compulsory Training for all staff G Rolling programme of training and education affected by turnover of staff and current vacancy level. All staff aware of personal responsibility for skill and training requirement. Seconded CNM gaining access to TURAS and EESS platforms. Skills Bus has been delayed from Nov/Dec 2022 however team has been contacted again to provide dates.
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Develop an electronic staffing roster on MS Teams G All staff will have visibility to this for transparency, any amendments made are audited allowing staff to trace/track all changes. Await the new PCT CNM to commence post in July then discuss and agree on the roster format. Review of addictions pathway for released prisoners G Addictions Charge Nurse invited to share current pathway with Drug Death Task Forum. This group is due to meet on 23rd July 2023 Water outlet not been utilised G Outlets have been removed and room is ready for preparation to store room facility. Seconded CNM is reviewing requirements to push work forward. Patient Feedback A Health Improvement advisor based at prison has confirmed the restart of Satisfaction Questionnaires from April 2023. Dates for focus groups yet to be confirmed. Health Improvement advisor left post in April ‐ eCOR to be raised to backfill and continue this work. Training in relation to End of Life Care G Anticipatory Care Planning (ACP) training/refresher for staff to be arranged •Staff to complete Lanarkshire ACP training module on learn pro. Confirmation of death training to be arranged for all appropriate staff. Clinic team to develop a pack containing appropriate and relevant resources that can be shared with bereaved families.
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Service Model Review Closed Actions RAG Update Robust process for monthly NMC Registration checks for Registered nurse to be established G Robust monthly process implemented by Senior Nurse, and undertaken by CNM as routine monthly task. Proactive approach to reminding staff that Registration fees are due for renewal. Proactive approach to ensure staff undertake Revalidation exercise timeously and in advance of due date for sign off. Introduction of Daily Safety Brief G Template for safety brief updated, agreed and implemented. Morning safety brief being completed by Primary Care Team at beginning of shift and electronic copy saved in R‐drive. Introduction of 2pm verbal briefing started 8th May 2023 by CNM, includes MDT representation.6pm Safety handover completed by PCT Nurse on duty at end of working day. Emailed to colleagues and Senior management team for info Introduction of a Monthly Health Centre Team/Service meeting G CNM re‐commenced these meetings in April 2023 Staff Health & Well Being G Discussion with SPS staff at Strategy group ‐ unable to provide alternative rest area but staff can utilise facilities at main reception for breaks, this also includes use of Gym facilities. Staff breaks extended to include time to walk to main reception if staff wish to utilise this area. Weekly staff email bulletin includes up to date information for all staff re how to access staff health and wellbeing facilities. Radio chatter distraction to staff G Discussed at Strategy Group, and agreed clinical staff should remove ear piece when issuing medication. Communicated this to staff. Health & Safety G Control Book reviewed end of November 22 with Action Plan issued. CNMs tasked with completion and/or delegation of tasks. Control book reviewed and on continuous review and update as risk assessments are required. Psychological Safety G iMatters survey due reviewed July 2023 as annual plan. Psychological survey carried out with staff for anonymous feedback ‐ will be repeated at regular intervals in the calendar year. Develop guidelines in relation to SPS purchased social care services G Senior professional & operational management have raised concerns to SPS at joint NHSL/SPS strategy forum. SPS did not share concerns expressed, but agreed to further investigate individual episode of alleged suboptimal care. NHSL will continue to raise concerns if required using appropriate medium. Individual investigation was investigated and concluded to NHSL satisfaction.
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Competent witness training G Register of all staff completing Competent witness training now being completed and CNM responsible for ensuring this is kept up to date. PDD to be contacted by SN to request review of training pack. Discussion completed with Practice Development. Review of kardex's G Process in place with regular review and re writing of medication kardex (Prescription sheet). Missing kardex’s within pharmacy G Test of changed developed and instated by way of sign in and out tracer card within pharmacy to reduce time wasted searching for kardexes when they are not in their allocated folder or with the GP. Completion of hand Hygiene learn pro module annually by all staff G Learn pro hand hygiene module records are held in this database and are being updated by CNM monthly. CNM is completing 10 hand hygiene audits each month with team and submitting on Monthly Highlight report for North hygiene group. Request to CNM for all completed audits to be recorded monthly on LanQIP ‐now completed onto LanQIP system Ensure all staff are fully aware of appropriate use of Personal Protective Equipment (PPE) G Winter Respiratory guidance and posters shared with CNM by SN. Request to share with team as well as posters to be displayed in all clinical areas. SN re‐shared Winter Respiratory guidance with all staff, including Respiratory questions and Quick Reference pathway which fully outlines appropriate use of PPE. Above guidance now added to admissions paperwork and staff now complete the questionnaire for all prisoners transferred into HMP Shotts during the admission process Prompt added to Daily Safety Brief as well as discussion at Morning safety handover to ensure all staff were fully aware of update. SN ensured posters were visible in relation to this guidance in health centre area for staff reference Ensure all staff fully aware of local guidance re cleaning and decontamination of environment and equipment G A‐Z Decontamination checklist shared by Senior Nurse (SN) to CNM and request for this to be completed as applicable. SN shared laminated posters with staff with instructions on use of appropriate cleaning agents‐ request for these to be displayed in Health centre area for staff reference. Cleaning schedules are available in all clinical rooms and staff are aware re completion of these at end of each room use.
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Completion of monthly SICP's audits as per SICPs Monitoring Audit Programme G Monthly SICP'S audits are completed by CNM, reported and submitted on Highlight report for collation by SN. SN shared annual SICP'S Monitoring audit programme with CNM. Request to CNM that all SICP'S audits are recorded on LanQIP when complete‐ this is now being actioned. Scottish Infection Control Education Pathway added to staff learn pro training scorecards for completion by all appropriate staff and record of completion will then be available for CNM to review. CNM will ensure staff complete. Poor compliance by all patients with PPE guidance and physical distancing G This advice continues to be reinforced for all patients attending Health centre area. Ensure all staff fully aware of national and local guidance in relation to infection prevention and control G Winter Respiratory guidance and posters shared with CNM by SN, Request to share with team as well as posters to be displayed in all clinical areas. SN re‐shared Winter Respiratory guidance with all staff. This included Respiratory questions and Quick Reference pathway which fully outlines appropriate use of PPE SN shared IPC team contact details as well as email link to IPC guidance for staff use by email as well as laminated posters displayed in health centre area for staff reference when required. Ensure all sharps bins are temporarily closed G CNM has discussed this with staff and is ensuring all staff are fully aware of how to temporarily close Sharps bins and correct labelling of bins. SN shared appropriate signage re Temporary closure of sharps bins with staff and request to display these in all appropriate clinical areas where sharps bins are used.
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Cancellation of patient transport G Database is being completed and updated daily to record any Geo‐amey cancellations. CNM is ensuring all cancelled appointments are reviewed daily to prioritise need for re‐appointment for individual prisoners. All cancellations appointments are reviewed by clinical staff and prioritised when requesting re‐appointments. Review of joint NHS Scotland and SPS MORS Policy G Discussed at local strategic meeting with SPS Staff and agreement that SPS staff should always action request from NHS staff to commence MORS Policy. NHS staff should escalate to Governor/Deputy Governor if any SPS staff refuse to commence MORS policy when requested. National review of MORs policy on‐going. SPS and Healthcare work in collaboration to review safety of patients. Ongoing national discussions regarding MORS. Appropriate use of ACP G SN shared updated copy of ACP booklet as well as the ACP Guidance for Health Professionals. CNM to share and discuss appropriate use of this with team. Staff to consider use of ACP booklet when indicated for individual patient completion. Review current escalation process for deteriorating patients G Training completed in 2022 for staff however change of staff will mean more training later this year. Closing as this will be a rolling programme of education.