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Women Offender Programs and Issues

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Nova Institution for Women

Section 4: Healthcare

Expected outcomes:
Inmates should be cared for by a health service that assesses and meets their needs for healthcare while in prison and which promotes continuity of health and social care on release. The standard of healthcare provided is equivalent to that which inmates could expect to receive in the community.


 
4.1

Women in our survey were more positive about the overall quality of healthcare than women prisoners in England and Wales. There had been no health needs assessment, but there had been a survey of the quality of provision. The nurses had a wide range of skills and competences, but there were insufficient formal systems and processes, and no identified lead. A decent primary care service was provided, although some women could wait too long to see a general physician. Healthcare accommodation was cramped. Outside appointments were generally met, but there were some delays for physiotherapy. There was potential for transcription and other errors in handling prescriptions. Health promotion was good, with impressive management of infectious diseases. Mental health services, led by psychology, needed better integration with healthcare.

 
  Environment
 
4.2 The healthcare space was very cramped, having been designed for a smaller population. The waiting area was part of the corridor. It had comfortable seating and some health promotion material. The entrance door did not have a bell, and anyone other than healthcare staff had to knock on the door for entry. There was room for only one woman at any one time. At the entrance there was an administrative office and a small area for administering medications, with a hatch through to the waiting area. There was only one clinical room, which had a small desk and a treatment couch. The nurses shared an office, although there was another small office away from the main department that the infectious diseases nurse used.

4.3 All medications were stored in one room, where all other medical stores were also kept. There were two drugs fridges. One was used to store methadone and was locked, and the other contained both vaccines and food. Fridge temperatures were not monitored regularly. There was a separate fridge for storing specimens.

4.4 A small emergency kit with bandages and other first aid equipment was kept in the medicines room, and there was also a spinal board and oxygen. There were open tubes of antiseptic cream in the kit. There were no documented checks of the equipment.

4.5 The institution did not have a defibrillator or an emergency childbirth kit. The local hospital was close by, but we did not consider this a satisfactory alternative.


  Staffing
 
4.6 Six registered nurses were in post. There was no chief of healthcare and each nurse had a specific responsibility, reporting to the deputy warden. However, this meant there was no clearly identified clinical lead. The nurses worked shifts to provide cover from 8am until 8pm, Monday to Friday, and 10.30am until 7pm at weekends. All the nurses were licensed to practice. An administrator worked five hours a day. During our inspection two nursing students were on an elective placement at Nova.

4.7 The nursing staff undertook some professional development, but none had received update training in resuscitation in the previous 12 months. None of them had any formal clinical supervision. They had a yearly performance development plan and appraisal with the deputy warden.

4.8 Two general physicians from the local community provided medical cover. One was available from 1pm to 2.30pm on a Wednesday afternoon for three weeks out of four for the general population. They also provided a fortnightly clinic for women in the secure and segregation units.

4.9 A psychiatrist held one half-day session a fortnight. Nurses from the Victoria Order of Nurses provided foot care clinics every six weeks.


  Records
 
4.10 Clinical records were kept in the nurses' office in the healthcare department. The documentation was of variable quality, and did not note when an inmate left the institution. The clinical notes were archived but could be retrieved if a woman returned and a temporary file was used until this arrived. Faxed copies of notes from emergency or routine hospital appointments were obtained to maintain continuous records of treatment. Dental records were filed in the clinical records. The psychologists kept separate case files about each of their clients.

4.11 Doctors' prescriptions for medications were written in the clinical records and transcribed by nurses on to the pharmacy-ordering sheet. The medication administration records were computer generated by the pharmacist and kept in alphabetical order in the medicines store. The nurse faxed orders for repeat medications to the pharmacy. There appeared to be little or no audit of pharmacy ordering. If a woman refused medications, after discussion with her the nurses put a yellow line through the prescription to indicate that it had been stopped.

4.12 Nursing staff worked to a variety of standing orders, some of which were repeated, so they were confusing. We were concerned that one of them stated that nursing staff could discontinue medications if a woman had been involved in a violent act or had self-mutilated. Staff appeared unaware of this policy and assured us that this never occurred.


  Delivery of care
 
  Primary care
 
4.13 Provision of healthcare services was not based on a needs assessment. A healthcare accreditation of the department had been carried out in early 2005, but this assessed quality of provision rather than checking that practice met need.

4.14 Nurses saw new arrivals, usually within a few hours of arrival, for preliminary checks, including a basic mental health assessment. Women were referred to a psychologist if deemed necessary. The inmate handbook included information about healthcare services.

4.15 The infectious diseases (ID) nurse saw women within two weeks of their arrival for a comprehensive interview on infectious diseases and risk factors. This included the first part of a two-stage TB test, which was repeated annually. There were also questions and tests for hepatitis, HIV/AIDS (including pre- and post-test counselling) and sexually transmitted diseases. The results of all tests took four to six weeks. The ID nurse gave women their results and arranged further blood work or an appointment for them to see the doctor as necessary. The results were also sent to CSC headquarters. Women could request a repeat of the ID screen at any time while at Nova. Anyone with suspected TB was transferred to the local hospital as Nova did not have isolation facilities.

4.16 The ID nurse also presented group teaching sessions about infectious diseases, prevention and treatment. Women who attended these received a bleach kit and a contraceptive pack with condoms, lubricant and dental dams.

4.17 There was a computerized database of all patients' annual health assessments, such as TB tests, pap tests and the need for an influenza vaccination. However, this was not kept up to date. There was also a paper-based system, which seemed more reliable.

4.18 If an inmate wanted to see a member of the healthcare team she could submit a written request. However, most simply spoke to staff when they collected their medications or at 8.40am during the assessment and sick passes time. Some women just knocked on the door of the department at other times. They could also contact nurses by telephone from their house via the front desk.

4.19 Nurses worked to standing orders and could administer some medications. They referred women to a doctor if necessary.

4.20 A female general practitioner attended for two hours for three weeks out of four to see women from the general population. On the fourth week she attended the methadone multidisciplinary meeting. Women said they waited too long to see the doctor, and it could take three weeks from arrival to be prescribed medications. There was no doctor's clinic during our inspection due to the methadone meeting. By the Wednesday of that week there were already eight on the list to see the doctor the following week. If many more women needed to see the doctor on that day the list would be prioritized and not everyone would be seen. This was unacceptable.

4.21 The doctor also attended the secure and segregation units once every two weeks, when she saw all residents.

4.22 Medications for the general population were administered at four treatment times during the week and three treatment times at the weekends. Methadone was administered at a separate time. Women had to queue up outside the administration block and were let in one at a time by one of the two primary workers who supervised the queue. Nurses removed tablets from blister packs before the medication time and put them in small pill boxes with a patient's name. This was poor practice and unnecessary.

4.23 Medications were given through the hatch from the healthcare department and most were administered as 'direct observation'. Medicines were usually supplied for 30 days unless the prescription was for a shorter duration. Women were not asked for identification. Some medications, such as antibiotics, were given in-possession without any documented risk assessment. Medication charts were annotated at the time of administration.

4.24 Women told us that hypnotics were administered at 7.30pm, which they considered too early, and we were given examples of women falling asleep while trying to complete homework for their programs. This was poor practice. If a specific medication was prescribed to be given when nursing staff were not on duty it was put into an envelope and given to the residential officers' supervisor (ROS) to give to the patient at the appropriate time, when both parties signed that it had been administered.

4.25 Methadone was administered at 8am during the week and 11.30am at weekends. One nurse had specific responsibility for methadone. She liaised with the women taking it and attended the monthly methadone meetings. The five women on methadone had to provide identification for nursing staff to administer the drug. They took the methadone, which was pre-mixed with a fruit juice, while standing at the treatment hatch and had to sit in the waiting area for 20 minutes before leaving, observed by two primary workers, to ensure that it had been ingested.

4.26 The weekend morning treatment time of 11.30am was a problem for Aboriginal women who attended an Aboriginal 'sweat' on Saturday morning and so were unable to collect their morning medications. Other women were also unhappy about the different treatment times at weekends. One commented in our survey about the negative effect of the treatment times on her medical condition.

4.27 Women in the security and segregation units had their medications taken to them. They were administered from the visits room with a primary worker in attendance.

4.28 Women could not see a pharmacist to discuss their medications, and there were no information leaflets about any medications they were prescribed.

4.29 Nova did not have a dental suite on site, and women attended a community dentist. As with other outside appointments, staff tried not to book them until after the inmate's security status was clarified, which could take up to 90 days. Nursing staff undertook dental assessments, but had had no specific training to do so. In our survey, only 16% of respondents rated the dentist as good or very good.

4.30 Physiotherapy was also not provided on site. We were told that women on the maximum security and segregation units were not sent out for treatment. Only two women at any one time could go on physiotherapy sessions and, if others had just begun, a woman could wait up to 20 weeks, to be seen.

4.31 All other waiting lists were managed by the relevant health professional in the community. Women said that staff who escorted them to outside appointments were usually respectful, and there were no unnecessary security measures. One woman commented about how kind staff had been.

4.32 There was other health promotion activity in addition to the infectious diseases program. There had been a health fair in July 2005. Pap smears were taken yearly, and a mobile mammography scanner had been to Nova (all women over 40 were entitled to a mammography screen). Although staff estimated that 90% of women smoked, no smoking cessation services were offered. There were plans to introduce these as part of a CSC policy to ban smoking in institutions in early 2006. Women could buy nicotine replacement therapy from the healthcare department, but this was not widely known. There were no weight management or healthy eating programs.

4.33 The healthcare department closed at 8pm. If a woman became unwell after this time she was expected to use simple remedies bought from the canteen. In emergencies, officers could contact paramedic services. Each house also had a first aid kit. It was the responsibility of the house rep to check this and replenish it from the healthcare department as required. However, women we spoke to were unaware of this.

4.34 A nurse saw women before release and provided one month's supply of any prescribed medication, gave the opportunity to be tested for infectious diseases, and gave out a contraceptive pack and useful contact telephone numbers. They also received a copy of all blood work and pap smears taken while they were at Nova. Staff did not help them to register with a doctor unless the woman required ongoing medical treatment. If ongoing treatment for an infectious disease (such as hepatitis C) was needed, staff made assiduous efforts to ensure they had pre-arranged appointments at an infectious diseases clinic. Healthcare staff were not always informed of a woman's release sufficiently far in advance, and arrangements for ongoing treatment were often made at extremely short notice.


  Mental health
 
4.35 The psychology department managed mental health services. There were three psychologists at Nova - one responsible for the general population, one for the SLE and the third for the secure and segregation units. They did not receive clinical supervision so relied on peer support. Parole officers, primary workers and healthcare staff could refer women to the psychologists, and women could also self-refer. The psychologist for the general population had a caseload of 30 clients, and used cognitive behavioural therapy techniques to help them with issues such as adjustment, depression and anxiety. Most clients were seen once every two weeks for an initial eight weeks and then their case was reviewed. The psychologists kept their own case files.

4.36 One of the nurses had extensive mental health experience. She was based in the security and segregation units and also had responsibility for women in the SLE. She delivered the psycho-social rehabilitation program.

4.37 A psychiatrist saw women in the general population once every two weeks, and those in the security and segregation units in the week in between. The psychiatrist was responsible for prescribing anti-psychotic medications and hypnotics. The psychologists could refer women to the psychiatrist, and arranged urgent consultations if necessary. If a woman was seeing both the psychologist and the psychiatrist, the psychologist tried to be present for her consultation with the psychiatrist. The psychiatrist sent the psychologist a copy of his clinical notes but the psychologists did not copy their notes to anyone.

4.38 There was a brief, monthly, mental health meeting attended by psychologists, the mental health nurse, a member of the case management team, and the chaplain. Women who had arrived in the previous month were discussed, but they were not present. There were very brief notes of the meeting, which were circulated to those present, but discussions about individuals were not recorded in their clinical, psychology or any other personal file

4.39 When a woman seeing a psychologist was discharged the psychologist either concluded her therapy or recommended future sessions in the community as part of her overall case management file. It was then the responsibility of the community to provide the service.


  Action points
 
4.40 A health needs assessment should be carried out to determine whether the services meet the needs of the population including mental health needs. This should include a workforce and skill mix review.

4.41 A chief of healthcare should be appointed.

4.42 The healthcare department should be large enough for purpose, and should include a dental suite.

4.43 An automated external defibrillator should be included in the emergency medical kit, and there should be an emergency childbirth kit.

4.44 All healthcare staff should have appropriate clinical supervision.

4.45 There should be annual training for staff in resuscitation, first aid and 'first on scene' situations.

4.46 Triage algorithms should be used to ensure consistent assessment and advice.

4.47 Women should not have to wait outdoors for their medications.

4.48 The systems for obtaining prescribed medications and administration of medications should be improved to reduce possible transcription and administration errors.

4.49 There should be provision for all women, including those in the secure and segregation units, to receive night sedation at an appropriate time.

4.50 Women attending the Aboriginal ceremony at weekends should not miss medications.

4.51 Medical, nursing and security staff should develop a local drugs formulary and a formal risk assessment for in-possession medications.

4.52 Healthcare standing orders should be reviewed, clearly dated and based on evidence-based practice. All staff should be familiar with their contents.

4.53 Nurses should be trained to undertake dental assessments.

4.54 Women's access to healthcare services should not be restricted by their security status.

4.55 More general practitioner time should be provided so that women do not have to wait so long for an appointment.

4.56 Health promotion activities should include weight loss, healthy eating and smoking cessation programs.

4.57 The psychologists should share their notes with healthcare staff.

4.58 Clinical notes should provide a continuous, contemporaneous record of interventions.

4.59 The database for patients' annual health assessments should be contemporaneous.


  Housekeeping points
 
4.60 Minimum and maximum temperatures of all fridges used to store heat-sensitive medications should be recorded daily, and these medications should be stored between 2 and 8 degrees Celsius.

4.61 Food should not be stored in the same fridge as vaccinations.

4.62 Tubes of cream/ointment etc should be for individual patient use only and open tubes should be discarded.

4.63 Patient information leaflets should be available for all medications.


  Good practice
 
4.64 The infectious diseases screening and program was exemplary.

4.65 The efforts by nursing staff to ensure that women had continuity of care when they left Nova, often with little notice of their discharge, were commendable.