HMP & YOI Styal

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

At our previous inspection, we found poor infection prevention and control practices; insufficient staffing levels; and issues with the safe management of medicines. At this inspection, we found the provider had made improvements and was no longer in breach of the regulations. The provider had improved their systems and processes for prescribing, recording and storing medicines. The provider had a medicines improvement plan that clearly set out further areas for development. The provider had significantly improved infection prevention and control practices and staff ensured high levels of cleanliness and hygiene in clinical areas. While staffing remained a challenge, the provider had successfully recruited new staff, the service had a more stable team, and shifts had safe staffing levels. The provider had reviewed and improved their clinical systems and processes, which helped ensure that patients received timely assessment and interventions. However, we identified areas that the provider should improve further. The provider should: continue to improve the process for ensuring people get their critical medicines and review the procedure for escalation when people don’t attend to collect them; ensure access to homely remedies in a timely manner, especially simple analgesics; continue to improve the process for regular review of patients’ ‘medicines in-possession risk assessments’ (MIPRAs); ensure patients receive their medicines on release and that this is recorded accurately so the provider can monitor compliance; ensure medicines reconciliation is covered in policy and procedures and staff understand their responsibilities for this process; and ensure patients with asthma receive their inhalers.

Find out what we look at when we assess this area in our information about our new Single assessment framework.

The judgement for Learning culture is based on the latest evidence we assessed for the Safe key question.

Staff ensured that patients received good quality reception screening assessments. Urgent health issues were identified promptly and responsive actions taken by staff to address them. We found examples of patients who needed emergency treatment on their arrival, who were assessed and treated effectively. A dedicated nurse supported patients with long-term health conditions and ensured they received regular reviews and the appropriate monitoring and checks associated with their conditions. Staff prioritised patients with high levels of risk, for example, those with insulin-dependent diabetes. Records showed that patients were well monitored and received timely interventions when needed. Patients in need of follow up checks were booked into clinics or placed on the relevant waiting lists. Clinical managers completed ‘daily assurance checklists’ that covered standards and expectations in clinic rooms including emergency bags, equipment, and medicines. Our review of these checklists showed that staff identified issues and took remedial actions. This process had successfully improved and embedded good practice, and the checks now took place 3 times weekly.

The process for patients’ healthcare applications had improved. Nurses on night shifts collected and processed the paper applications daily. There was no backlog of applications. Managers had developed and placed clinical resource files in each clinic room with a tailored one for reception. These held information, tools and guidance on a wide range of topics such as health conditions, clinical pathways, and essential medicines. Clinical areas had medical emergency bags that contained the appropriate equipment and supplies, which were in date. Staff completed frequent checks and identified any actions needed, which were then addressed promptly. Managers had improved the daily safety huddles. The meetings were multi-disciplinary (pharmacy, mental health, substance misuse, primary care, GP, and midwifery), and included the governor. The 30-minute meetings were well structured with a clear agenda that covered urgent daily matters including missed critical medicines, new prescriptions, clinical issues, risks, hospital admissions, updates, close monitoring of patients at risk, codes received, and new receptions. Any staff could add items to the agenda in advance via the ledger or at the meeting. We observed 2 huddles during our inspection and found them to be well-managed, well attended, with good participation, covering urgent issues, sharing information especially about risk. Any actions arising from the meeting were followed up.

The judgement for Safeguarding is based on the latest evidence we assessed for the Safe key question.

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

The judgement for Safe environments is based on the latest evidence we assessed for the Safe key question.

The staffing profile for primary healthcare was gradually improving with successful recruitment and new staff due to start imminently. Retention had improved, especially with new staff, who received a robust induction and support. The service still relied on (regular) temporary staff but received more cover from its own staff and bank staff. The service model and associated resource levels remained insufficient to meet the needs of the prison population but commissioners had provisionally approved the provider’s business case for additional staffing resource. However, funds had not yet been released, which meant that the service had to continue operating on less than optimum staffing levels. Overall, the service had a more stable and reliable team and it was evident that staff worked hard to minimise the impact of staffing shortages on patient care. The provider monitored staffing levels closely, which included forecasting, identifying and escalating potential shortfalls, and taking remedial actions. On occasions where planned staffing fell short due to unexpected absences, managers ensured they deployed the available resources effectively to maintain patient safety, for example, by prioritising clinics, and undertaking clinical activities themselves. We reviewed 3 months of staffing rotas from July to September 2024. Rotas were fully completed. We found that staffing levels rarely fell below Spectrum’s safe staffing level of 7 staff per day time shift and 2 nurses for night shifts. There were only 2 occasions during this period when the provider needed to notify CQC of the risk of unsafe staffing levels, and only 1 of these resulted in the need to implement contingency plans.

Compliance levels with all mandatory training had increased. Managers had good oversight of training needs and enabled staff to complete their training requirements. The frequency and quality of supervision had improved significantly. Staff had access to planned two-monthly supervision with their line managers. Supervision sessions covered a range of topics including practice issues, the staff member’s health and wellbeing, and training needs. In addition, all staff had access to weekly group reflective practice sessions that covered a range of topics such as long-term conditions, practice issues, and policies and guidance. In addition to supervision sessions, all staff had access to regular monthly team meetings. The arrangements for social care provision remained the same with there being a dedicated social care coordinator available during week days, with other times covered by the healthcare staff on duty and the 2 nurses on night shifts. The provider planned to increase the staffing levels at night to include a healthcare support worker. As the level of social care need varied due to continuous population changes, this meant the level of demand on primary health care staff was also variable. At the time of this inspection, the level of need was relatively low and patients were receiving the care they need in a timely way.

The provider had an infection control lead who carried out regular audits of the environment and standards of cleanliness. This had been effective in identifying numerous areas that fell below the required standard and actions had been taken to address these, such as clarifying expectations and implementing cleaning checklists. We found improved levels of cleanliness in healthcare areas and clinic rooms. Equipment, including methadone dispensing machines, was cleaned regularly and thoroughly. Staff had access to hot water is all clinic rooms. Staff we spoke understood their role in keeping the environment clean. Joint working with the prison had improved and there were good communication channels to report and manage any issues. This had led to improvements in the standard of general cleaning undertaken by prison staff, a schedule of regular cleaning of light fittings and plans to add extra tasks to the regular maintenance schedule. Issues remained with the environment, such as worn and dirty flooring and damaged work surfaces. Spectrum had raised these issues with the prison and some work was due to start immediately after our inspection, such as replacing the flooring in some clinical areas. New equipment had been ordered to replace items that were no longer fit for purpose, such as waste bins and storage for items like dressings.

Medicines were dispensed from an onsite pharmacy and administered from MAPs. Medicines administration on Waite wing MAPs was effective. Medicines administration on the health care unit remained a challenge but the provider was trying out different approaches to address this. At the time of our inspection, there were 2 queues at the 2 MAPs, one for regular medicines and one for opioid substitution treatment (OST). However, staff found that patients did not want to queue up twice to receive their medicines from the different MAPs, and this was increasing the number of missed medicines. The provider was due to revert back to a single queue to address these concerns. During our inspection, we reviewed how patients’ medicines were managed on their release or transfer. Most patients received a 7-day supply of their medicines, patients on 'in-possession' (IP) medicines could take their remaining IP medicines, and patients on methadone received a prescription or had an appointment booked with a community drugs team. There were contingency arrangements in place for immediate releases if the pharmacy was not open. However, the data we reviewed showed that only 60% of patients being transferred and 16% being released were supplied with their medicines. Although this was mostly explained by data capture issues identified by the provider, we found 1 person who had been released without their medicines or a discharge letter outside of pharmacy opening hours. Patients had complained about delayed access to homely remedies to treat minor ailments. This had a greater impact on patients who managed their own medicines (IP) who did not attend MAPs. The provider was aware of this issue and was exploring options to provide homely remedies more efficiently.

The provider had strengthened the ‘in possession’ (IP) process to reduce risks. At the time of our inspection, 38% of patients were prescribed medicines IP. IP patients had recently had their ‘compact agreements’ (signed contracts) renewed, reiterating their responsibilities. A robust programme of spot checks had been introduced to check if patients were complying with their compact agreements for having their medicines in possession, for example, ensuring secure storage and taking medicines as prescribed. Staff worked closely with the prison team to undertake checks, prioritising high risk and tradeable medicines, and responding to intelligence. Staff completed a form following a spot check, which set out their recommendations, for example, to review or terminate the patient’s IP status. Patients with IP status collected their medicines at designated clinics that took place on Friday afternoons. Patients could also collect their medicines at the weekend if they missed the designated clinic. However, patients who did not attend to collect their medicines were not always followed up by staff. We checked the records of 10 patients who were prescribed inhalers to manage asthma symptoms and saw that 3 patients had not collected their inhalers and had not been followed up by staff. The provider had started to review ‘medicines in possession risk assessments’ (MIPRAs) to check they accurately reflected the status of the patient. However, further improvements were required. For example, we found a patient who had been given 28 days’ medicines instead of the 7 days indicated in their MIPRA. We informed staff and this was rectified immediately.

We observed temperature monitoring in all areas where medicines were stored. Staff now logged the current, minimum and maximum temperatures of the room each day. Air conditioning was available to mitigate high temperatures and guidance was given on how to report temperatures that were over 25°C for 5 days. The lead pharmacist monitored these areas and assessed the likely impact on medicines. The provider had applied for funding to install temperature data loggers that would record temperature over a period of time. The provider had improved the storage of available medicines at medicines administration points (MAPs). This meant that staff had better access to the medicines they needed to administer, which in turn helped with timely administration and a reduction in missed doses. The provider had plans to expand one MAP to further improve the storage of medicines. Staff undertook weekly checks of the areas where medicines were stored to ensure safe and appropriate storage. A range of emergency medicines was also available in the MAPs, with systems and processes in place to manage them safely and effectively. During our inspection, we found the pharmacy team had no oversight of complaints involving medicines and were not included in their investigation. However, changes to the procedure were in progress, which would mean that medicines-related complaints would be discussed at the medicines committee. We found that due to challenges with pharmacy staffing, structured medicine review clinics for patients were yet to start. We saw that staff completed medicines reconciliation checks for all new patients but we were unable to locate a policy that set out the relevant procedures and staff responsibilities for the safe continuation of patients’ prescribed medicines.

Staff completed regular audits of missed medicines, and were aware when patients did not receive their medicines. There were still a proportion of medicines not being administered for 3 primary reasons: the drug was unavailable, the patient refused their medicine, or the patient did not attend for their medicine. However, the incidence of medicines being unavailable for administration had decreased from 24 occasions in July 2024 to 7 in September 2024. Staff escalated incidences of missed critical medicines such as insulin and anti-psychotic depot injections at the daily safety huddles but this did not include other missed critical medicines such as antibiotics and anticoagulants. We also found 4 occasions between May and September 2024 where patients did not receive their depots on time. In each case, primary care and mental health staff worked together to investigate the reasons and agree a solution. While this remained a risk, the transfer of the responsibility for the administration of depots to the mental health team was imminent. Prescription stationery was managed safely. There were legal authorisations or prescriptions in place for all medicines administered to patients. Our review of medicines records showed that staff completed medicines administration records fully and accurately. Controlled drugs were managed safely and in line with legislation. Methadone was reconciled every day and accurately reflected in the controlled drugs book. The management of emergency medicines had improved with good availability of critical medicines, effective stock control and recording of usage.