Report

by the Comptroller
and Auditor General

Home Office and NHS England

Yarl’s Wood Immigration Removal Centre

HC 508 Session 2016-17 7 July 2016

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Report by the Comptroller and Auditor General

Ordered by the House of Commons
to be printed on 6 July 2016

This report has been prepared under Section 6 of the National Audit Act 1983 for presentation to the House of Commons in accordance with Section 9 of the Act

Sir Amyas Morse KCB
Comptroller and Auditor General
National Audit Office

5 July 2016

This investigation focuses on the new contract management arrangements and the relationships of the commissioning bodies, the Home Office and NHS England, with their contractors, Serco and G4S. It looks at the extent to which these were a factor in criticisms of Yarl’s Wood, specifically those arising from the various reviews.

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11011 07/16 NAO

The National Audit Office study team consisted of:
Charlotte Knowles, Eleanor Murray, Tosin Omole, Ee-Ling Then, and Poppy Sparham, under the direction of Louise Bladen.

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Key facts

Summary

Rationale for work

1 Yarl’s Wood is an Immigration Removal Centre (IRC) that provides secure accommodation for women, adult families and, on a short-term basis, men whose cases are being assessed. The largely female and transient population at Yarl’s Wood has complex needs. Residents can come from many different countries of origin, are often vulnerable and can suffer from mental health issues. Yarl’s Wood has often been subject to considerable scrutiny. As the main IRC for women in the UK, it has been a focus of substantial public and media concern about the detention of women and children.

2 Yarl’s Wood has been run by contractors, on behalf of government, since it opened in 2001. The Home Office is responsible for all aspects of Yarl’s Wood except healthcare, which is now commissioned by NHS England. Following the award of new contracts, Serco has run the residential services under contract to the Home Office since April 2015 and G4S has run the health services under contract to NHS England since September 2014. Prior to that, Serco provided all services under contract to the Home Office.

3 In March 2015, a Channel 4 undercover documentary on Yarl’s Wood made allegations about the way residents were treated by staff. The documentary coincided with the start of the new Serco contract. It was closely followed by an unannounced inspection of the centre by HM Inspectorate of Prisons (HMIP) and the Care Quality Commission (CQC) in April 2015. Since then, there have been a further four independent reviews. These were led by Kate Lampard for Serco, Stephen Shaw for the Home Office, Bedford Borough Council’s Adult Services and Health Overview and Scrutiny Committee and the CQC. The reviews covered different aspects of the performance of Serco and G4S. The Home Office, NHS England, Serco and G4S subsequently drew up plans to respond to the reviews, and are introducing changes. Figure 1 sets out the key events at Yarl’s Wood.

4 Contrary to media allegations, none of the recent reviews found evidence of a culture of abuse. The Lampard Review found that most residents were largely positive about their relationships with staff. The HMIP report found that 80% of residents surveyed said most staff treated them with respect. The reviews also reported positively in a number of areas including accommodation, recreational facilities and dental services. Provision of faith services in particular was highlighted as being very good.

5 The reviews also identified a number of problems, and there were common themes between them. These included:

the quality of the services and facilities provided, for example residents, many of whom were vulnerable, were not able to access a comprehensive mental healthcare service;

the needs of residents and the extent to which they are being met, for example staff were not properly trained to understand residents’ experiences, and there were not enough female staff; and

the management decisions and measures taken by contractors to ensure that services meet residents’ needs, for example residents who had been victims of torture were not identified when they arrived, or identified quickly enough.

6 Concerns about operations at Yarl’s Wood were first raised directly with us in late 2014 to early 2015 and came from several sources. We decided to wait until other reviews, in particular the CQC and HMIP inspections were complete before beginning our own inquiries. Our investigation has focused on the new contract management arrangements – an area where we felt we could add expertise given our past work. While the various independent reviews identified problems at Yarl’s Wood, we have sought to understand what caused them:

how far the problems identified by the reviews were caused by gaps in the new contracts between the Home Office and Serco, and NHS England and G4S;

how far the gaps were caused by the contractors failing to fully implement the requirements of the contracts; and

the extent of progress in addressing the gaps in provision.

7 We found that there were three broad ways in which the Home Office and NHS England’s approach to contracting out services played a role in the problems that the reviews found at Yarl’s Wood:

problems arose as a result of the Home Office’s contract. For example, the contract for residential services permitted a reduced number of staff at Yarl’s Wood. Staff shortages were criticised by a number of reviews, and some of the posts have now been reinstated;

problems arose because there were gaps between the service specifications of the two contracts and no clear way to resolve them. For example, there was a lack of clarity about who was responsible for archiving old medical records, dealing with clinical waste and deep cleaning medical facilities. Partnership Boards, including both departments and contractors, took place from November 2014. Both contractors told us that while they could raise concerns with the departments, there was no clear process for resolving them; and

problems arose because although an issue was covered in the contract, the provisions in the contract were not fully implemented. For example, the healthcare contract requires G4S to provide mental health training for all staff, including Serco staff on site. The contract took effect from September 2014, but the training was not offered to Serco staff until April 2015, and no Serco staff were able to attend until October 2015. To date, 27% of all Serco staff have undertaken the training.

Key findings

Designing the service specification

8 The Home Office did not reflect lessons from previous inspections when it agreed the service specification with Serco. Many of the concerns raised by HMIP in its 2015 inspection were raised in 2011 and 2013 prior to the new contracts. For example, HMIP identified issues with the quality of Rule 35 reporting (the process for identifying vulnerable residents) and the role of male staff in searching female residents’ rooms. At the time of the 2015 report, 59% of the 2013 report’s recommendations had not been achieved, with little evidence that issues had been tackled until recently (paragraphs 1.31, 2.12 and 3.2).

9 While the move to self-service in the residential services contract reduced demands on staff time, Serco’s reduction of staff meant there were insufficient operational and management staff. The contract envisaged freeing up staff time by moving to a ‘self-service’ model where, for example, residents send their own faxes and book their own visits. While the self-service model has reduced demands on staff time, numbers were reduced too far. Serco has now made further changes to the staffing model. It has replaced some of the posts that were removed, changed shift patterns, reintroduced specialist teams and increased staff training (paragraphs 2.12 to 2.17).

10 NHS England brought healthcare expertise but did not have a good understanding of the particular needs of residents when it designed the service specification. Although NHS England had over a year to prepare, the mental health service it initially commissioned did not meet the needs of the residents at Yarl’s Wood. In part, this was because it did not know enough about the health needs of people at Yarl’s Wood, because data which NHS England would usually have accessed was not previously collected and available to them. When NHS England took over the contract, it commissioned a range of services for residents with a mental health diagnosis. However, it initially did not fund counselling services which had been used previously to prevent deterioration of mental well-being and to cater for residents who had not been diagnosed with a specific mental illness, despite the high prevalence of mental health issues among the resident population. After reviewing its service in October 2015, NHS England reintroduced counselling for residents who had not received a specific diagnosis. This was introduced in April 2016, some 18 months after the health services contract started (paragraphs 1.14 and 3.2 to 3.6).

Gaps in the service specification

11 Services at Yarl’s Wood did not fully meet the needs of users, in part because there was a lack of clarity about which contractor was responsible for what. Where multiple parts of the public sector are providing services to the same groups of people, it is important to ensure that the services ‘wrap around’ the user. It took time for all parties to become familiar with their responsibilities under the new contracts, and progress resolving issues was slower that it could have been. In practice this has resulted in delays in improving some services (such as dispensary facilities) and took considerable management time to resolve. However, joint forums have been set up to facilitate discussion and the main issues have been resolved (paragraphs 3.7 to 3.9).

12 The service specification takes some account of the diverse needs of residents, but more can be done, particularly in the performance and financial regime. The performance measures in the contracts do not explicitly consider service quality, via user feedback. Indeed, there is an example where the performance model and other contract changes have indirectly led to worse treatment of residents. In the new contract the Home Office significantly increased the penalty for residents absconding and now requires Serco to escort residents to out-of-area hospitals which are unfamiliar to staff. The Home Office has published guidance that states that there is a presumption against the use of handcuffs during visits to outside facilities, and any use should be following an individual risk assessment. Although no resident has ever absconded on a hospital visit, Serco told us that it is now more likely to use handcuffs due to the combination of more risky hospital visits to unknown hospitals and the much higher penalty if a resident absconds. 3% of women were handcuffed for hospital visits between October 2014 and April 2015. That figure rose to 11% for the same period the following year, when the new approach had been implemented. The Yarl’s Wood Independent Monitoring Board (IMB) found that some residents have refused to go to hospital visits as they find the practice of handcuffing humiliating (paragraphs 2.7 and 2.8).

Failure to deliver the specified services

13 The contracts required that training should be provided but staff at the centre were not adequately trained to deal with the particular concerns, issues and vulnerabilities of those in immigration detention. For example, training did not sufficiently address uncertainty in immigration status, the indefinite nature of detention and difficult experiences such as having witnessed or been victims of traumatic events, violence, abuse and torture. Serco has now addressed this with a review of the content and range of courses available (paragraphs 2.12 to 2.16).

14 G4S has been slow to meet its contractual obligations for training. G4S was required to provide staff with appropriate training on IRCs. Rule 35 assessments are specific to IRCs so people who had not worked in IRCs need training about them. The HMIP repeatedly issued recommendations to address weaknesses in the Rule 35 process during inspections in 2011, 2013 and again in 2015. However, neither commissioners nor contractors acknowledged the urgency of addressing these main recommendations. NHS England eventually provided training to GPs in July 2015, almost a year after the G4S contract started. G4S was also required to provide training to all staff at Yarl’s Wood on mental health issues. NHS England did not enquire in the first six months of the contract whether G4S was providing mental health training to Serco staff. G4S offered training to Serco staff in April 2015, seven months after the start of the contract, but Serco was not able to take it up until October 2015. Training is now offered on a monthly basis (paragraphs 3.2 to 3.5).

Contract management

15 NHS England has limited powers to withhold payment if G4S does not deliver the service it is paying for, and has never withheld payment. NHS England did not withhold payments on the two occasions when it issued a ‘breach notice’ for G4S performance problems because it considered that they were quickly resolved. It has not set out how much it expects to recover in the event that G4S fail to deliver elements of the service it pays for (paragraph 1.24).

16 The Home Office contract is over-engineered and creates large theoretical financial credits for even trivial deviations from the contract. The Home Office is working on making it more streamlined. For example, if the Yarl’s Wood gym opens five minutes late then this could generate a service credit. If Serco keeps the gym open for an extra five minutes at the end of the day, this would be acceptable mitigation and the service credit would not be imposed. The Home Office has imposed £56,000 of service credits out of a total of £585,600 credits generated, because it considered that there were mitigating circumstances for the vast majority of them. It is in the process of reducing the number of performance indicators from 120 to around 30, so that it can focus on any serious problems rather than requiring Serco to report every technical deviation from the contract and the mitigations it puts in place (paragraphs 1.22 and 1.23).

17 The Home Office and NHS England are content that the performance information they receive from their contractors is generally very accurate, although on a small number of occassions it has contained errors. They rely on Serco and G4S to self-report their performance against the contracts as part of their performance management regime. Both the Home Office and NHS England also conduct audits of specific elements of the service. Errors have occassionally been identified both by the Home Office and NHS England, and by the contractors who conduct their own reviews (paragraph 1.21).

Progress since the reviews

18 There has been some significant progress since the independent reviews, although 35% of the recommendations from HMIP’s 2015 inspection have not yet been implemented. In particular, there have been improvements to healthcare facilities, the gender balance of operational staff, adult safeguarding and the residential regime. The CQC re-inspected healthcare at Yarl’s Wood in May 2016, and found that all the required improvements had been made, and there was only one area requiring further work (paragraphs 2.9 to 2.11, 2.16 to 2.17, 2.22 to 2.25, 3.5 to 3.6, 3.9, 3.13 and Figure 10).

Concluding comments

19 The new contracts to run residential and health services at Yarl’s Wood did not initially meet the needs of the vulnerable population detained there. Despite both NHS England and the Home Office having time to prepare for the new contracts, some of the problems that arose were foreseeable, and had been identified by previous inspectorate reports. Both commissioners and contractors, however, are now making progress in responding to the reviews and fixing the problems identified by them.

20 Many measures to secure value for money in public services do not easily apply to services for people who may be vulnerable. Unlike some public services, Yarl’s Wood residents are not able to choose a different provider if they are unhappy with the service they receive. NHS hospitals use a ‘friends and family’ test (whether the patient would recommend the service to friends and family) that would clearly be inappropriate in Yarl’s Wood. Residents may not speak English, and may be unwilling to complain from a fear that raising a complaint may have an impact on their immigration case. It is therefore particularly important that departments commissioning services for vulnerable groups consider how they will know whether the services that people receive represent good value for money.

Lessons for commissioning services for vulnerable groups

21 We have identified some good practice and lessons learned at Yarl’s Wood for departments to consider when setting up contracts to provide multiple services for vulnerable groups. This is particularly relevant as new contracts are being set up across the Immigration Removals Estate over the next few years:

Managing a transition to multiple providers

In order to plan services properly, providers taking over from an incumbent provider need access to information about the service and the needs of the group receiving the service. This is particularly important where the group served is vulnerable and has complex needs. Departments should consider how they will ensure this happens, for example, by adding a requirement to provide this information to successor bodies for new contracts. Successor bodies may also need to seek information in greater detail in the final year of the contract to ensure that the service is fully understood at the time of service transition.

Where multiple organisations are responsible for providing a service, the departments involved should agree how they will resolve issues that appear to fall between contracts or create unforeseen interdependencies between multiple services. This should include timescales for resolving issues, for example, on an issues log. It is unlikely to be possible to identify all of the interdependencies between services in advance, so it is important to agree the approach to resolving these issues when they emerge. It may also be helpful for suppliers to develop cooperation agreements, particularly where they depend on each other for aspects of the services they provide.

Recognising users’ needs

Users’ needs may not be obvious, and may change over time. When designing the contractual arrangements, departments should consider including arrangements to:

define the group’s characteristics and any needs that may require more attention or specialist intervention;

assess users’ needs when they first come into contact with a service, and identify needs that develop while using the service;

take account of the users’ perspective when assessing contractors’ performance, for example in evaluating service quality; and

carry out an early review of the adequacy of the service, and ensure that there are mechanisms for varying the contract or buying more services if necessary.

Where several public sector organisations are providing services to the same group of people, it may be helpful to design joint or shared performance targets, to help assess whether users are receiving a well-integrated service.

Contract management

All contracts should follow good practice in contract management, for example, setting a proportionate number of key performance indicators (KPIs) that are clear and have targets linked to a system of penalties and incentives.

Where there are a number of similar services, for example, across the IRC estate, the department should consider developing a core set of KPIs to enable it to compare and benchmark performance. This should be complemented by stand-alone indicators relevant to individual establishments.

Overview of the rest of the report

22 The rest of this report provides:

an introduction to the Immigration Removal Estate and to Yarl’s Wood in particular, including details of the contracts under which Serco and G4S run the centre – it also sets out the common areas of concern identified by the different reviews (Part One);

analysis of the issues raised by the different reviews around residential services and residents’ feedback, the extent to which they were covered by the contracting process, progress in implementing the reviews’ recommendations, and the gaps that remain (Part Two); and

analysis of the issues raised by the reviews about healthcare services, the extent to which they were covered by the contracting process, progress in implementing the reviews’ recommendations and the gaps that remain (Part Three).

Part One

Background

1.1 This part provides an introduction to:

immigration detention policy;

Immigration Removal Centres (IRCs);

Yarl’s Wood IRC;

the roles of the Home Office and NHS England and their approach to managing the contracts for services at Yarl’s Wood; and

recent reviews of Yarl’s Wood.

Immigration detention policy

1.2 The Home Office is responsible for setting and enforcing immigration policy. It aims to enforce immigration laws robustly, with detention and removal from the UK as elements of immigration control. The Immigration Act 1971 first included the power to detain immigrants, and later legislation has built on this.1 People who may be detained include those:

who have just arrived in the UK and will be examined by an immigration officer to decide whether or not they can be granted entry;

who have entered the UK illegally (for example, in the back of a lorry or using false documents);

who have overstayed their limited leave to remain, or who have breached conditions attached to their leave to remain; and

against whom the Home Office is taking deportation action.2

1.3 Not everyone who falls into one of these categories is detained. If Home Office immigration officials decide to detain people, they must record the decision and give the reason. Possible reasons for detention include:

removal from the UK is considered ‘imminent’;

the person is considered likely to abscond;

there is not enough information to decide whether or not to allow a person to be admitted or released;

release is not considered to be ‘conducive to the public good’; or

alternative arrangements are being made for the person’s care but are not yet in place.3

1.4 In 2015, 32,446 people were detained. This was 7% more than in 2014. Over the same period there was a 12% increase in those leaving detention; 45% of these people were removed from the UK. Figure 2 shows the number of people entering and leaving detention in the UK over the past five years.

Immigration removal centres

1.5 People who are detained may be held in IRCs, short-term holding facilities (STHFs) or, if they are time-served foreign national offenders or they present a security or control risk, in prison. IRCs are required by law to provide secure but humane accommodation of detained persons. This must be in a relaxed regime that allows as much freedom of movement and association as possible, consistent with maintaining a safe and secure environment. IRCs must help and encourage those who are detained to make the most productive use of their time, while respecting their dignity and their right to individual expression.

1.6 These conditions align broadly with international guidelines set out by the United Nations High Commissioner for Refugees.4 Two guidelines are particularly relevant:

Guideline 8 sets minimum conditions for detention and states that conditions must be humane and dignified.

Guideline 9 states that the special circumstances and needs of the particular individuals must be taken into account, recognising that they may be victims of trauma, torture, or trafficking and that particular groups like those who have disabilities, are women, older, lesbian, gay, bisexual or transgender will need special care and assistance.

1.7 There are nine IRCs across the UK; seven are managed by private sector companies under contract to the Home Office, while two are operated by the National Offender Management Service. They range in size from Heathrow in Middlesex (Colnbrook and Harmondsworth), which has capacity for 1061 men, to Tinsley House at Gatwick, which has capacity for 119 men.

Yarl’s Wood

1.8 This report focuses on Yarl’s Wood, an IRC.5 Yarl’s Wood has been run by private contractors since opening in 2001. It is the main accommodation for female detainees in the UK, and most occupants are women. It includes three residential units for single women, one unit for adult families and a STHF for single men. It houses one of the largest concentrations of women detained anywhere in Western Europe.

Yarl’s Wood’s population

1.9 IRCs typically house people of many nationalities, backgrounds and languages. Many have little or no command of English. During 2015, 3,969 people entered Yarl’s Wood from 111 different countries, including Iran (14%), Eritrea (13%) and Iraq (10%).6 The population is transient: in March 2016, the average length of stay ranged from one to 60 days depending on the type of resident (see Figure 3). The resident who had stayed longest had been in detention for 490 days.

1.10 Residents of IRCs may have witnessed or been victims of traumatic events, violence, abuse and torture. When HM Inspectorate of Prisons (HMIP) inspected Yarl’s Wood in 2015, nearly half of the female residents surveyed said they felt depressed or suicidal on arrival. In 2015, about 12% of residents were ex-prisoners, an increase on previous years.

1.11 Not everyone who is detained in Yarl’s Wood is deported or removed from the UK. Of 5,261 people who left Yarl’s Wood in 2015, 19% were deported or removed from the UK (Figure 4).

Roles of the Home Office and NHS England

1.12 The Home Office used to be responsible for commissioning one contractor (who may then subcontract some services) to provide services in a privately-run IRC such as Yarl’s Wood. However, following the Heath and Social Care Act 2012, responsibility for IRC healthcare was to be transferred from the Home Office to the Department of Health on 1 April 2012, and to NHS England on 1 April 2013.

1.13 The Home Office and NHS England agreed that the Home Office would continue to manage the existing contracts on behalf of NHS England until September 2014, so that NHS England could focus on the tender process for the new contract.7 In December 2013, NHS England launched a tendering process to commission integrated healthcare services for four IRC estates, including Yarl’s Wood.

Operational pressures

1.14 Both NHS England and the Home Office were operating under challenging conditions. External pressures were also a factor in determining the new contract arrangements:

The Home Office chose to make savings across its contracts to meet the government’s requirement to reduce spending. The new Yarl’s Wood contract will cost £42 million less than the previous one over the maximum 11-year life of the contract. Savings come mainly from replacing some staff with self-service kiosks.

NHS England was new to immigration detention. It took on a service that was not at the standard it expected. The previous contract did not contain details of the healthcare that the service provided.

1.15 Under the new arrangements, a single contract was split into two with separate contractors. The Home Office, NHS England and the contractors found it difficult to manage these changes, and they did not work effectively together to integrate the two services. In Part Three, we examine early problems concerning lack of clarity about who was responsible for services that were on the boundary between healthcare and residential services.

Management of Yarl’s Wood IRC

1.16 Following the transfer of responsibility for health services to NHS England, the Home Office and NHS England ran separate procurement processes to commission residential and healthcare services. Serco won the tender to deliver residential services for the Home Office, and G4S won the tender to deliver healthcare for NHS England. The main events in Yarl’s Wood’s management are set out in Figure 5. Figure 6 gives an overview of the contracts since 2007.

1.17 NHS England and the Home Office took different approaches to running the procurement exercise, structuring the contracts and measuring performance. Figure 7 sets out the differences. The Home Office placed a greater emphasis on bid price during the tendering process, with a higher weighting on cost (45%) than NHS England (20%).

1.18 NHS England designed the contract with G4S to provide primary healthcare, equivalent to what would be available from a GP in the community, and secondary mental healthcare. NHS England routinely commissions health needs assessments, and an independent assessment of Yarl’s Wood took place in August 2013. It reported a high prevalence of mental health problems, self-harm and disclosure of torture within the population. It noted that the mental health provision at that time did not appear to be meeting residents’ needs. It made a number of mental health related recommendations, including that prevalence rates should be monitored.

1.19 The 2013 assessment was a brief update of the 2010 assessment at Yarl’s Wood, and was supposed to help shape the service specifications for the new contract. The tender for the new service was launched in February 2014. NHS England told us that the health needs assessment could not be used to inform the service specification due to time pressures. It published the invitation to tender with the intention to review the service specification following contract award. NHS England then commissioned a full health needs assessment in 2015 on the basis of which it is making changes to the contract for services at Yarl’s Wood.

Performance management

1.20 Both the Home Office and NHS England hold monthly meetings with their contractors to discuss performance. In addition, there is a quarterly partnership board, which is attended by the Home Office, NHS England, G4S and Serco. The partnership board first met in November 2014, two months after G4S took over provision of health services at Yarl’s Wood. Within the Home Office, commercial specialists independently scrutinise the operational teams’ monitoring of the contract, and review the level of service credits imposed.

1.21 The Home Office and NHS England rely on Serco and G4S to self-report their performance against the contracts as part of their performance management regime. They consider that the information they receive is generally accurate. Both bodies also conduct audits of specific elements of the service. On occasion, both contractors have notified the departments that the performance data they have supplied has contained errors. The Home Office and NHS England contract management teams have also identified errors in the performance information they receive.

1.22 There are significant differences in how the Home Office and NHS England provide incentives to improve. The Home Office contract contains 120 key performance indicators (KPIs). It applies service credits if Serco fails to meet the required standard, and can issue a remedial notice, which requires immediate improvement, in the case of serious breaches. Between April 2015 and March 2016, Serco incurred service credits worth £585,600. It paid a total of £56,000 across 29 different KPIs after the Home Office accepted there were mitigating circumstances for most of the issues.

1.23 In early 2016, in response to feedback from Serco and operational staff that the performance regime was complex to administer, and in line with a contractual commitment to review the performance framework after a year, the Home Office began a review of the number of KPIs. This work is ongoing, but the Home Office expects to reduce the number of key performance measures from 120 to around 30. Performance not covered by the new KPIs will be reported by Serco via a new management information schedule.

1.24 NHS England has begun to trial incentive payments to improve performance. It can issue a ‘remedial notice’ or a ‘breach notice’ in cases of serious breaches. It may terminate the contract if the breach is repeated within the period of the notice or another serious breach occurs. NHS England has issued two remedial notices where G4S was unable to provide GP appointments. The contract allows NHS England to withhold or deduct payments if G4S fails to address the subject of a notice. It has never done so as G4S addressed both notices issued. It has not set out how much it expects to recover in the event that G4S fail to deliver elements of the service it pays for.

1.25 NHS England reformed its approach to monitoring health services in Yarl’s Wood in September 2015 with a pilot of monthly Health and Justice Indicators of Performance (HJIPs). These indicators will be standardised across all secure settings (including prisons, IRCs and other secure and detained settings). They will cover outcomes, use and uptake of services. HJIPs monitor performance but do not include performance targets. They do not cover user satisfaction with services or complaints. G4S is contractually obliged to obtain the opinions of service users and NHS England monitors this during an annual audit and at monthly meetings.

1.26 We analysed HJIP pilot data covering September 2015 to February 2016 and found cases where indicator data were missing or inaccurate. Reasons for this included certain services not being offered, inaccurate data, or failure of Serco or the transport services provider to supply the required data. A new IT system was introduced in March 2015 which has improved data quality and consolidates information which was previously unavailable.

1.27 There are no integrated performance measures between the contracts. The Committee of Public Accounts has previously noted the importance of ensuring effective integration between different government departments running projects for the same group of people.8,9

Yarl’s Wood in the spotlight

1.28 Since opening in 2001, Yarl’s Wood has often been in the news. As the main IRC for women in the UK, it has been a focus of considerable public and media concern about the detention of women and children. Media concerns have also included:

Serco’s involvement in the centre, as a private sector organisation;

the day-to-day running of the centre – in particular, allegations of staff misconduct; and

shortcomings in healthcare.

1.29 In March 2015, a Channel 4 undercover documentary on Yarl’s Wood made allegations about staff treatment of residents. During its inspection, HMIP conducted both surveys and interviews with Yarl’s Wood residents. It found that detainees were generally positive and most said that most staff treated them with respect. It observed a positive culture in the centre. In respect of the allegations made by some detainees relating to healthcare (specifically mental health care and antenatal care), NHS England undertook an independent review of the specific cases. The antenatal care was found to be excellent. The review of psychiatric care found that it could and should have been better, but was not necessarily worse than the patient would have received in the community.

Inspections and reviews of Yarl’s Wood IRC

The HMIP and CQC inspection

1.30 In April 2015, HMIP and the Care Quality Commission (CQC) conducted a joint unannounced inspection of Yarl’s Wood. HMIP had previously inspected Yarl’s Wood in 2011 and 2013. These inspections focus on four ‘healthy establishment tests’, which cover:

safety;

respect;

activities; and

preparations for removal and release.

1.31 The results of the 2015 inspection showed that conditions at Yarl’s Wood had deteriorated against three of the four tests since 2013 (Figure 8). At the time of the 2015 report, 59% of the 2013 report’s recommendations had not been achieved, with little evidence that issues had been tackled until recently.

1.32 The CQC had last independently inspected Yarl’s Wood in 2013, at which point the service met all five of its standards:

respecting and involving people who use services;

care and welfare of people who use services;

cleanliness and infection control;

supporting working; and

assessing and monitoring the quality of service provision.

Other reviews of Yarl’s Wood

1.33 There have been a further four recent reviews of the centre. The reviews were:

The Shaw Review into the welfare in detention of vulnerable persons

This review was commissioned on behalf of the Home Secretary and announced via a written ministerial statement on 9 February 2015. It focused on Home Office policies and operating procedures that have an impact on the welfare of immigration detainees across the immigration detention estate. It was published in January 2016.

The Lampard Review

This review was commissioned by the chief executive and board of Serco plc, and carried out by Kate Lampard, a former barrister and current NHS executive. It focused on the overall culture at Yarl’s Wood and how this affects the welfare and well-being of residents. It was published in January 2016.

Yarl’s Wood Immigration Removal Centre Health Services Review

This review was carried out by the Adult Services and Health Overview and Scrutiny Committee of Bedford Borough Council. It focused on standards of healthcare and mental health assessment for residents in Yarl’s Wood.

The CQC Quality Report

The CQC inspected the centre in March 2016 to check that the service had met the requirements of the Requirement Notices issued during the 2015 joint inspection with HMIP.

Common areas of concern

1.34 The recommendations and observations in the reviews addressed a wide range of topics and concerns. These broadly focused on:

the quality of the services and facilities provided;

the management decisions and measures taken by contractors to ensure that their services meet those needs, particularly in terms of staffing and staff training; and

whether the specific needs of residents are being met.

1.35 The main points arising from the reviews are presented in Figure 9. In the next part we examine these areas more closely in the context of the contracting arrangements. We also look at what has been done at Yarl’s Wood so far to address the issues raised.

Responding to the reviews and overall progress

1.36 The Home Office and NHS England responded to each of the reviews with action plans, monitoring and external validation of progress. Each has a plan to address the recommendations. They discuss progress with contractors at monitoring meetings and quarterly partnership board meetings. The Home Office Returns Assurance and Audit Team monitors progress towards implementation of third party recommendations. Figure 10 shows the progress that the Home Office and NHS England consider they have made in addressing HMIP’s recommendations.

1 For example, Immigration Act 2016, Nationality, Immigration and Asylum Act 2002, UK Borders Act 2007, Immigration and Asylum Act 1999.

2 Partnership agreement between Home Office Immigration Enforcement, NHS England and Public Health England, April 2015, page 5.

3 Enforcement Instructions and Guidance, Chapter 55 – Detention and Temporary Release. Home Office, UK Visas and Immigration, published 10 December 2013.

4 United Nations High Commissioner for Refugees, Detention guidelines: guidelines on the applicable criteria and standards relating to the detention of asylum-seekers and alternatives to detention, 2012.

5 While this report focuses on IRCs, some of our findings may also be relevant for other types of detention centres, such as STHFs.

6 Home Office, National Statistics: Detention, 25 February 2016

7 Until April 2015 for Colnbrook IRC.

8 Comptroller and Auditor General, Integration across government, Session 2012-13, HC 1041, National Audit Office, March 2013.

9 HC Committee of Public Accounts, Programmes to help families facing multiple challenges, Fifty-first Report of Session 2013-14, HC 668, April 2014.

Part Two

Residential services and residents’ feedback

2.1 This part covers three main areas of concern identified by the recent reviews (meeting residents’ needs, staffing and management and quality of services) with regard to the residential services provided by Serco. It also covers the routes by which residents can raise concerns or complaints about health or residential services at Yarl’s Wood.

2.2 For each area of concern it examines:

the specific issues raised by the reviews;

how these issues were considered when the contracts were being let; and

progress since the reviews, and what more needs to be done.

Meeting residents’ needs

Issues raised by the reviews

2.3 Yarl’s Wood residents may be vulnerable for a number of reasons (paragraphs 1.9 to 1.10). Some are seeking asylum, and the United Nations High Commissioner for Refugees (UNHCR) detention guidelines advise that the special circumstances and needs of particular asylum-seekers must be taken into account (paragraph 1.6).

2.4 Several reviews of Yarl’s Wood found shortcomings in the approach taken to identifying and treating vulnerable residents. A summary of the main recommendations and observations relating to residents’ needs is provided in Figure 9. The issues identified in the reviews resonate with issues raised in a March 2016 report by the Committee of Public Accounts on contract management. The report found that departments are not always holding contractors to account for meeting users’ needs, especially vulnerable groups, and there is a risk that the user’s voice is not heard.10 Specifically, the reviews commented on the following themes:

Identifying vulnerable residents

The HMIP report found that procedures to protect the most vulnerable women were underdeveloped and there was still no formal link with the Bedford Borough Council Safeguarding Adults Board.11

Recognising diversity

HMIP found that “the strategic management of equality and diversity was underdeveloped. There was no action plan, identification of protected characteristics was weak and monitoring of treatment and conditions rudimentary”.

Bullying and violence

The HMIP report found that “most violence was low level but it had increased significantly and far more detainees felt unsafe than at the previous inspection. Detainees’ perception of safety was affected by several issues, many of which reflected weaknesses in processes and services in the centre”.

Well-being

The Shaw Review identified shortcomings in the policies designed to maintain well-being, particularly the risk-averse approach to preventing self-harm and suicide due to the absence of a ‘therapeutic environment’. The HMIP reported that some assessment, care in detention and teamwork cases (ACDT), which identify and support residents at risk of suicide or self-harm, were opened without evidence that the resident was at risk of self-harm.

Staff training

The Lampard Review found that policies and training materials “contain, for instance, little or no acknowledgement of the particular concerns, issues and vulnerabilities of those in immigration detention, including the uncertainty over their immigration status, the indefinite nature of their detention, and the mixed population in an IRC like Yarl’s Wood.”

2.5 Residents whose mental or physical health is likely to be harmed by being placed in detention should be identified through medical screening, and reported to the Home Office. This process is known as a Rule 35 procedure. We consider this in Part Three, which deals with health services.

How were these issues considered in the contract?

2.6 The Home Office included the following provisions in the contract to take account of residents’ needs:

Identifying vulnerable residents

The Home Office required Serco to identify those at risk of suicide or self-harm and provide care and support for them. It also required Serco to produce a prevention strategy. Serco staff at Yarl’s Wood hold regular meetings to discuss residents at greater risk, including people who are about to be removed to their country of origin, at risk of self-harm, or pregnant. Serco must publish a safeguarding adults policy that sets out how at-risk adults will be protected and also establish safeguarding arrangements in partnership with the local authority.

Recognising diversity

The contract refers to the “age, gender, cultural, educational and ethnic needs of a diverse population” when covering communication, activities and library facilities.

Bullying and violence

Serco is required to develop, operate and manage a violence reduction and anti-bullying/antisocial behaviour strategy that provides support to victims and requires bullies to address their antisocial behaviour.

Well-being

The contract requires Serco to provide well-being services to meet residents’ needs, taking account of their welfare, race and religious affairs. This includes, for example, providing appropriate clothing, welfare services, activities, facilities for prayer, religious services and pastoral care. On-site facilities include a shop, library, gym and internet access. The contract also requires Serco to follow ACDT procedures to support residents at risk of suicide or self-harm, and provide ACDT training to staff.

Staff training

The contract requires Serco staff to have training on the identification of, and procedures for dealing with, vulnerable detainees.

2.7 The contract sets out key performance indicators (KPIs) that the Home Office uses to monitor whether it is getting the services it pays for. These measures cover some aspects of dealing with vulnerable residents, including whether Serco is communicating with residents in the relevant language; allowing people to participate in activities and monitoring any problems of access to activities for particular groups.

2.8 In some instances, the Home Office’s decisions about the contract had a negative impact on vulnerable residents. For example, as part of the new contract, it introduced a category of ‘significant performance failures’. These cover incidents of suicide and escape from detention or escort. They are rated as ‘critical’ and ‘very high’, with associated penalties of £30,000 and £10,000 should an incident occur. This is significantly higher than levels set in the previous contract. The new contract also requires that patients are taken to out-of-area hospitals with which Serco staff are not familiar. The Home Office has published guidance on the use of handcuffs when escorting women outside an IRC, for example to hospital. It states that there is a presumption against the use of handcuffs during visits to outside facilities, and any use should be following an individual risk assessment. Serco updated its risk assessment for hospital visits in October 2015 to take account of the contractual changes. Although no one has ever absconded on a hospital visit from Yarl’s Wood, Serco told us that it is now more likely to use handcuffs due to the combination of more risky hospital visits (to unknown hospitals) and the much higher penalty if a patient absconds. No patients were handcuffed in the first five months of the contract. In the 7 months after Serco updated its risk assessment in October 2015, 11% of women were handcuffed for hospital visits, compared to 3% of women from October 2014 to April 2015. In its 2015 Annual Report published in June 2016, the IMB recommended that the use of handcuffs for hospital visits should be investigated to ensure that efforts are made to limit its use, while addressing any security concerns. It also noted that some residents have refused to go to hospital visits as they find the practice of handcuffing humiliating.

Progress and what more needs to be done

2.9 In January 2016, the Home Office announced that it intends to adopt a wider definition of vulnerable residents, by introducing a new definition of adults at risk. The new adults at risk draft policy was published in May 2016. The definition includes victims of sexual violence, pregnant women, people aged 70 or over, and people with learning difficulties or mental health issues, including post-traumatic stress disorder. The draft policy sets out government’s intention that fewer people with a confirmed vulnerability will be detained in fewer instances and that, where detention becomes necessary, it will be for the shortest period necessary.

2.10 The Immigration Act 2016 which received Royal Assent on 12 May 2016, provides that pregnant women who are to be detained pending removal or deportation, may be detained for a maximum of 72 hours. This can be extended up to a week with ministerial authorisation.

2.11 Serco has committed to improving safeguarding policies and practice. It has established a tri-annual keep-in-touch meeting with Bedford Borough Council Safeguarding Adults Board, which took place for the first time in April 2016. It has begun drafting a safeguarding adults policy, which will be presented at a Bedford Borough Council Safeguarding meeting in September 2016 for approval. It has also commissioned the Council as well as other organisations to provide training for centre staff. Specialised training covers topics such as dignity in care; safeguarding adults and children; and trafficking, exploitation and modern slavery. Serco is in the process of improving ACDT guidance and training, and expects to have completed this by August 2016.

Staff levels and training

What the reviews found

2.12 The reviews identified several shortcomings in the way Serco managed the centre. This included criticism of internal policies and procedures, cooperation and communication between service providers, and, most commonly, staffing issues. The main concerns about staffing were:

Lack of staff

The Lampard Review commented that low numbers of staff meant that there was not enough time to engage with residents. Low staffing levels at night created a risk that there were not enough staff to deal safely with emergencies. The HMIP report found overall staffing levels were inadequate, including management capacity.

Use of male and female staff

HMIP and Lampard both raised concerns about the appropriateness of male staff searching and supervising female residents. HMIP considered that there were not enough female staff to meet the needs of the mostly female population. HMIP had previously raised these issues in inspections in 2011 and 2013.

Training

Both HMIP and Lampard recommended that staff should receive more training in mental health, and to understand the residents’ backgrounds and vulnerabilities.

How were these issues considered in the contract?

2.13 The Home Office contract significantly reduced the number of staff at Yarl’s Wood. As part of the bidding process, Serco proposed cutting the number of staff by 19%. The contract envisaged that residents would carry out more tasks on a self-service basis, such as booking visits, ordering food and sending mail. The idea was that the change would “empower residents to take greater responsibility for their daily routine”. The self-service kiosks can be used in the languages most commonly spoken by Yarl’s Wood residents.

2.14 Serco removed about 30% of detainee custody officers, the middle tier of management and a deputy director post. Staff were trained to work in several different areas, rather than specialising. The new staffing model relied on overtime and agency staff to fill any gaps. At the contract evaluation stage, the Home Office recognised and accepted that this created some operational risks. The Home Office requires Serco to report actual daily staff numbers if they do not meet the target levels (which vary by time of day and occupancy levels). Failure to meet those levels can lead to penalties.

2.15 The contract also covers the recruitment of women and minimum training requirements. It requires Serco to train staff in race relations, equality and diversity and cultural awareness, identification of, and procedures for dealing with, vulnerable detainees and mental health awareness.

Progress and what more needs to be done

2.16 Serco has taken steps to address these concerns:

Lack of staff

Serco has put in place additional detainee custody officers and a new assistant director, revised shift patterns with specialist teams (for example, residential or reception teams), increased staff numbers at night to ensure that they are above minimum staffing requirements, and reviewed its promotion and development opportunities, including pay incentives to recruit more staff and try to reduce staff turnover.

Use of male and female staff

Serco has recruited more female staff. It intends to have 60% female staff at detainee custody officer level. As at March 2016, 55% of these are female and Serco is continuing to recruit.

Training

Mandatory training now includes half-day sessions on mental health, understanding the needs of asylum-seekers (run by UNHCR) and safeguarding (with Bedford Borough Council Safeguarding Adults Board). To date, 27% of all Serco Yarl’s Wood staff have attended the mental health training.

2.17 The Home Office does not have a complete picture of staffing levels at Yarl’s Wood as Serco is only required to report on staffing shortfalls when they occur more than twice a month. Serco have twice reported being understaffed in breach of this threshold between April 2015 and February 2016.

Quality of services: complaints and feedback

Issues raised by the reviews

2.18 HMIP found that complaints were generally well managed; however, it raised concerns about the confidentiality and timeliness of responses to complaints about healthcare. The Shaw Review also found that the number of complaints about healthcare in Yarl’s Wood was significantly higher than for any other IRC, and that the number was rising over time. HMIP raised a concern about whether the contractors knew the results of complaints, and were therefore able to learn from them.

How were these issues considered in the contract?

2.19 Both Serco and G4S must collect residents’ feedback through formal complaints procedures, surveys and resident forums. They should then use this feedback to shape their services. There are several ways that residents can provide feedback:

Meetings

Residents can raise issues at the resident information action committee, and Serco runs focus groups for nationality groups. Residents can attend the final part of equality action team meetings, a group run by Serco which focuses on equality practice. G4S runs monthly healthcare focus groups that are open to all residents, to discuss services and suggest improvements.

Surveys

Serco conducted two full resident surveys in 2015 and early 2016. It also ran two other surveys: for residents aged 18 to 25 and on anti-bullying. These were offered via online kiosks with a small financial reward as an incentive to complete them. G4S surveyed residents via kiosks around the centre and through paper-based surveys.

Complaints

Residents can make a complaint in Yarl’s Wood by completing a paper form and putting it in a post-box. A Home Office team then allocates complaints to Serco, G4S, NHS England or the Home Office. The Independent Monitoring Board, G4S and a diversity and equality adviser (employed by Serco) also operate separate processes.12 Both health and residential complaints can be made in any language. Healthcare complaints are responded to in the language in which they are made, but residential services complaints are responded to in English.

Healthcare champions

Healthcare champions are volunteers from the different residential units at Yarl’s Wood. They represent residents’ views and concerns about healthcare services at senior team meetings and resident forums.

2.20 G4S struggles with engaging residents. There are low response rates to its surveys, and low attendance at focus groups. G4S believes that this could be because residents are confused about the different ways of providing feedback or are reluctant to provide feedback on a system in which they are being unwillingly detained.

2.21 Both NHS England and the Home Office provide guidance on handling complaints. The Home Office has two KPIs relating to feedback. These are both categorised as ‘low’ priority: failure to arrange opportunities for detainees to be consulted on the services provided; and failure to have effective complaints procedures. Serco can be penalised if a complaint against it is substantiated. In the past year, seven complaints were upheld. In 2015, it received 110 complaints.

Progress and what more needs to be done

2.22 In August 2015, following the HMIP inspection, the Home Office and NHS England published joint guidance for the handling of complaints. Formal written complaints are collected and reviewed daily by Home Office staff, and healthcare complaints are handled under separate NHS complaints procedures. Once NHS England receives permission from residents, it sends complaints to G4S. G4S told us this prevents it from acknowledging complaints within the recommended time frame, which may upset residents or discourage them from raising concerns. G4S has therefore complemented the standard procedures with its own internal complaint system, which it responds to within three days.

2.23 The Home Office monitors the quality of Serco’s responses to complaints on a monthly basis. This review has identified problems with over 60% of responses in the period November 2015 to April 2016. The most common flaws include poor grammar, failing to respond to the specific concerns raised, and missing details, for example the job title of the staff member responding to the complaint. Of the 45 complaints received over this period, only one was correctly identified as partly substantiated. A further four comments should have been identified as substantiated or partly substantiated but were not. The Home Office reviewed responses to complaints in May 2016 and found that the overall quality of responses had greatly improved.

2.24 There is potential to get more useful information from complaints. The Home Office’s analysis focuses on how many complaints are received and how quickly they are dealt with, though it has recently started to develop an analysis of trends in complaints. NHS England receives a report on complaints from G4S each month. It discusses complaints at management meetings, and shares them with the Home Office, Serco and the Independent Monitoring Board at partnership board meetings.13

2.25 The Home Office contract has few quality measures, and neither feedback nor complaints feed into the formal assessment of performance. Serco told us it uses feedback to inform service improvements. For example, there was a change to the catering menu following comments about less fresh fruit being made available.

10 HC Committee of Public Accounts, Transforming contract management: progress review, Thirty-second Report of Session 2015-16, HC 711, March 2016.

11 The Bedford Borough Council Safeguarding Adults Board raises awareness and promotes the welfare of adults.

12 Every IRC has an Independent Monitoring Board. Its role is to monitor day-to-day life and ensure that proper standards of care and decency are maintained. It is staffed by volunteers.

13 Information about healthcare complaints is only shared within the parameters of patient confidentiality.

Part Three

Healthcare services

3.1 This part reviews three main areas of concern identified by the reviews (meeting the needs of residents, quality of services, and staffing and management) for the health services provided by G4S under contract to NHS England. For each area of concern we examine:

the specific issues raised by the reviews;

how these issues were considered when the contracts were being let; and

progress since the reviews, and what more needs to be done.

Meeting the needs of residents, particularly vulnerable residents

Issues raised by the reviews

3.2 The reviews identified a number of concerns regarding the protection and safeguarding of vulnerable residents, including victims of torture and those with mental health problems. These included:

Rule 35 assessments were inadequate

Rule 35 of the Home Office’s Detention Centre Rules aims to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention. Rule 35 assessments only take place if residents request them. IRC doctors complete Rule 35 reports and these are used by Home Office officials to decide whether detention is appropriate for that individual.14 HM Inspectorate of Prisons (HMIP) raised concerns about the quality of Rule 35 reports for the third inspection in a row, following inspections in 2011 and 2013. It found that many reports were incomplete, difficult to read and offered “wholly inadequate protection for some of the most vulnerable detainees” within the centre. Residents were also waiting too long for assessments.

Staff were not properly trained to identify vulnerable residents

HMIP found that health staff had not received torture awareness training, and most doctors had not been trained to complete Rule 35 reports effectively.

Mental health services did not meet residents’ needs

HMIP also reported that mental health provision did not meet the high levels of residents’ needs. Both the Independent Monitoring Board and Bedford Borough Council’s Adult Services and Health Overview and Scrutiny Committee raised concerns about the lack of counselling services. Serco had provided counselling services under the previous 2007 contract.

How were these issues considered in the contract?

3.3 NHS England place several specific obligations on G4S through the contract:

Rule 35 assessments

G4S are required to provide Rule 35 assessments in line with Home Office guidance. These assessments are only carried out if a resident requests one; G4S does not proactively identify residents for assessment. The Home Office advises that Rule 35 assessments should be performed as quickly as possible, resulting in a clear and legible report that should be sent to them without delay. A health and social care needs assessment commissioned in October 2015 found that residents were waiting up to 13 days for Rule 35 assessments, instead of the 24 hours recommended by HMIP. It concluded that this could prolong the time that vulnerable residents spend in detention, which could affect those with mental health issues.

Staff training to identify vulnerable residents

G4S must identify and support vulnerable adults, including those at risk of self-harm and with mental health problems. The United Nations High Commissioner for Refugees’ guidelines recommend that “because of the serious consequences of detention, initial and periodic assessments of detainees’ physical and mental state are required”. In addition to clinical care training, G4S must have in place training for staff covering customer care and adult safeguarding. It must also provide mental health awareness training for all staff, including those working for Serco. The contract took effect from September 2014, but the mental health training was not offered to Serco staff until April 2015, and no Serco staff were able to attend until October 2015. NHS England did not enquire in the first six months of the contract whether G4S was providing mental health training to Serco staff.

Providing services that meet residents’ needs

The contract requires provision of primary and secondary mental health services, with referral pathways to tertiary services where needed. G4S must work with Public Health England, NHS England and the Home Office to carry out regular health needs assessments of the Yarl’s Wood population. The assessment commissioned in October 2015 found that there were still no data on prevalence of mental health problems, despite this being a recommendation from the 2013 assessment. Without this data it remains difficult to assess whether services are meeting needs.

3.4 There was confusion over the contractual provision of counselling. Under the previous 2007 contract, Serco provided a self-referral counselling service to residents. When Serco’s healthcare contract ended in September 2014, this service was discontinued. NHS England commissioned mental health services including GP services, which may include prescribing anti-depressants, and referrals to talking therapies and secondary services. These services could be accessed by patients who were diagnosed by the Yarl’s Wood GPs as having mental health problems. However, Serco staff were unaware of the new approach and often directed residents to a counselling service which no longer existed. As a result residents without a mental health diagnosis were not being referred to the talking therapies services they required.

Progress and what more needs to be done

3.5 The Care Quality Commission (CQC) re-inspected Yarl’s Wood early in 2016 and identified many improvements since its last inspection enabling them to lift the improvement notices they issued in 2015. G4S and NHS England have made progress in a number of respects, though there is more to be done to embed some of the improvements:

Rule 35 assessments

In May 2016, residents in Yarl’s Wood waited 2.4 days on average for a Rule 35 assessment and the longest waiting time was 5 days. While this is a considerable reduction on the 13-day waiting time noted in the 2015 health and social care needs assessment conducted by NHS England, it is still in breach of HMIP’s recommendation of 24 hours. The Home Office intends to track Rule 35 reports under a new adults at risk policy.

Staff training to identify vulnerable residents

Doctors at Yarl’s Wood have now received specialist training on identifying and assessing torture. In July 2015, NHS England held a specific training day on recognising and treating victims of torture and trauma and completing Rule 35 assessments. G4S has also provided mental health awareness training to Serco officers. To date, 27% of all Serco Yarl’s Wood staff have followed the training, and training is offered monthly.

Mental health services to meet residents’ needs

3.6 Both commissioners and contractors have taken steps to improve mental health provision and awareness within Yarl’s Wood:

A mental health ‘care pathway’ had been introduced at Yarl’s Wood, to clarify the services available to Yarl’s Wood residents and how to access them.

Following the April 2015 inspection, NHS England and G4S agreed that G4S should provide additional on-site services to help residents to manage anxiety and sleep problems. These services were designed to provide support to residents, without starting in-depth treatment courses that they would not be able to complete if their immigration case was concluded during a course of treatment. The service started in May 2015, eight months after the termination of the Serco service. CQC found that residents appreciate this service.

NHS England provided grant funding to befriending services at Yarl’s Wood to support their work.

NHS England commissioned an additional on-site psychological well-being service which began in April 2016. This service offers talking therapies for residents with physical, emotional and substance misuse needs, and aims to provide therapy, although the intervention may be brief due to the length of stay.

NHS England commissioned a more detailed mental health needs assessment in IRCs from the Centre for Mental Health, an independent mental health charity.

The government committed to publish, by April 2016, a joint Department of Health, NHS and Home Office mental health action plan. This has not yet been done; the Home Office tells us that government is considering the arrangements for publishing it and expects to publish over the summer.

The quality of services and suitability of facilities

Issues raised by the reviews

3.7 The reviews identified concerns regarding:

Joint working between both commissioners and contractors

The reviews raised a number of concerns requiring the attention of both commissioners and contractors. Bedford Borough Council’s Adult Services and Health Overview and Scrutiny Committee concluded that the inability of NHS England to adapt or change the physical environment of the health centre limited the development of healthcare services. For example, while the report recommends that NHS England should take action to address the mental health needs of detainees, it also recommends that the Home Office and Serco should provide the necessary facilities.

Privacy and confidentiality in medicine management

HMIP found that residents had no privacy or confidentiality during drug administration. Residents received medication and requested services from the same area, the healthcare waiting room. HMIP found that pharmacy services were very poor and many residents did not receive their prescribed medication on time.

Servicing and maintenance of equipment and facilities

HMIP found that the healthcare waiting room was cramped and too small for the number of people using it. While the dental surgery facilities were reasonable, HMIP could not verify whether equipment was appropriately maintained as records were not available.

How were these issues considered in the contract?

3.8 While G4S is responsible for providing medical services, under contract to NHS England, Serco is responsible for providing and maintaining many of the facilities used. G4S provides medical services, including nursing, therapies, mental health services and substance abuse treatment, on a ‘turn key’ basis: that is, they should be able to turn the key, open the facilities and start providing services straight away, because the facilities are provided by Serco. This has led to uncertainty among some staff about how to achieve necessary changes leading to delays in resolving issues:

Services that fall between the two contracts

The contracts are unclear about who is responsible for providing services that fall on the boundary between healthcare and residential services. Some services are not listed in either contract. The uncertainty has led to disputes between Serco, the Home Office and G4S about who is responsible for carrying out certain recommendations. This has led to delays while a solution is found. For example, one of the CQC’s requirement notices related to the handling of patient records that pre-dated G4S’s service. While the issue had been raised against G4S, neither G4S nor Serco felt they were responsible for managing it, as it had not been specified in the contract. NHS England dealt with this by agreeing a solution with G4S, and providing funding for removing and archiving the documents.

Privacy and confidentiality in medicine management

The contract requires that healthcare services and facilities protect and preserve residents’ dignity, privacy and confidentiality. G4S must inform Serco and the commissioners when it feels the facilities are not conducive to this. The contract also requires G4S to ensure medicines are administered and supplied in a timely manner to residents.

Servicing and maintaining equipment and facilities

NHS England could not make provision for physical adaptations to healthcare facilities in the contract, as these are the responsibility of the Home Office and Serco. This means NHS England and G4S have to submit a request to the Home Office and Serco if they require any physical alterations to facilities. The healthcare contract also makes minimal reference to maintaining equipment. When HMIP made a recommendation to G4S regarding servicing and maintaining dental equipment, this was rejected because G4S considered that Serco was responsible for this. NHS England initially supported the rejection, but has subsequently identified an error in applying the contract and has reiterated with G4S its responsibilities for maintaining equipment.

Progress and what more needs to be done

3.9 Progress has been made against each of these areas of concern:

Joint working between both commissioners and contractors

Both commissioners and contractors have sought to resolve cross-boundary issues through discussion at the Partnership Board and regular joint management meetings. The Partnership Board was established to bring together the Home Office, NHS England, Serco and G4S. Serco offers G4S a standing invitation to its resident forums, while G4S gives Serco relevant information from its own patient forums. Both commissioners and contractors told us that these joint platforms provided useful opportunities to address issues at a senior level. However, our conversations revealed there are still concerns about the working relationships between front-line Serco officers and healthcare staff, which can create tensions. Staff gave us examples of behaviour that was viewed as divisive and not conducive to joint working. This included an unwillingness to participate in research if orchestrated or managed by the other contractor.

Privacy and confidentiality in medicine management

In January 2016, G4S opened a medication administration point, which is a separate area for supplying and administering medication. This provides an area for patients to access medication and seek advice confidentially, while also giving patients within the main healthcare area more confidentiality by reducing congestion in the waiting room. G4S also removed a glass barrier between staff and patients in the waiting room. The CQC inspection reported that recent improvements to the healthcare environment made it easier for patients to speak with health staff confidentially. The centre has established a Pharmacy Team, which provides oversight of medicine management.

Servicing and maintaining equipment and facilities

Review recommendations have been addressed through changes to facilities, including by creating the medication administration point. G4S keeps a record of cross-boundary recommendations and actions requested of the Home Office and Serco in their action plans. Progress against these recommendations is shared with NHS England. NHS England initially told us it has sometimes had to push hard to encourage the Home Office to take action, and it has also admitted that it has been slow to produce solutions on some occasions. It has since revised these views.

Staffing: levels, behaviour and training

Issues raised by the reviews

3.10 While most staff-related recommendations were aimed at the Home Office and Serco, the reviews also identified some concerns about healthcare staff:

Staff shortages

HMIP reported that severe staff shortages had contributed to a deterioration in healthcare provision since its last inspection in 2013. Despite a vigorous recruitment campaign and the use of agency nurses, there were chronic staff shortages.

Clinical leadership and training

A high turnover of senior health staff led to inconsistent clinical leadership. Staff shortages had restricted training opportunities for permanent staff.

Staff behaviour and attitude

In 2014, the Independent Monitoring Board noted residents’ complaints about rude and dismissive healthcare staff. In its 2015 Annual Report, it identifies the attitude and demeanour of staff as a principle area of concern, but acknowledges that improvements have been made throughout the year.

How were these issues considered in the contract?

3.11 The contract sets out the requirements for staffing:

Staff shortages

NHS England specifies in the contract that G4S should have sufficient staff in place with the requisite level of skill and experience to cover staff absences and increases in workload. G4S must also have contingency measures in place to ensure adequate staff cover.

Clinical leadership and training

The contract requires that visible and effective clinical leadership is in place. It also specifies that staff should have access to training and continuing professional development.

Staff behaviour and attitude

The service specification and contract obliges healthcare staff to be sensitive to the individual needs and diversity of residents. It also provides for residents’ feedback and complaints (paragraph 2.18).

3.12 Although a workforce plan is specified in the contract, NHS England has not asked G4S to provide one. Instead, it relies on G4S to report monthly on vacancies and recruitment.

Progress and what more needs to be done

3.13 Progress has been made in these areas:

Staff shortages

G4S reported that recruitment of permanent healthcare staff had been challenging, hampered further by the negative portrayal of Yarl’s Wood in the media. Senior managers sought to address this by investing considerable effort in challenging the negative perceptions of working at Yarl’s Wood during recruitment. G4S also awards financial incentives to staff who stay in post beyond six months. It told us that, as a result of these efforts, it is nearly at full complement. This means it is now relying less on agency staff and focusing more on recruiting permanent and bank staff. The CQC reported in May 2016 that staffing had been reviewed and, while recruitment was ongoing, the staffing profile was designed to better meet the needs of the centre population.

Clinical leadership and training

G4S told us it had invested further in training healthcare staff, with examples including training in long-term conditions for lead nurses and mental health awareness. Where possible, training was tailored to accommodate the health needs of the resident population, covering issues such as sickle cell anaemia and female genital mutilation. A training package for new starters is also in development.

Staff behaviour and attitude

The CQC reported that feedback from residents about staff’s attitude and consideration for patients’ needs was strikingly much more positive than in 2015. G4S also reported that the continued improvements to healthcare has had a positive effect on staff morale. Residents reported fewer incidents of dismissive or rude encounters with staff.

14 The Detention Centre Rules, Statutory Instrument, 2001: 238. Part II, Health Care, Rule 35: “The purpose of Rule 35 is to ensure that particularly vulnerable detainees are brought to the attention of those with direct responsibility for authorising, maintaining and reviewing detention. The information contained in the report needs to be considered in deciding whether continued detention is appropriate in each case.”

Appendix One

Our investigative approach

Scope

1 We conducted an investigation into Yarl’s Wood Immigration Removal Centre (IRC) in response to concerns that were raised with us in late 2014 to early 2015 from a number of sources. This report follows a number of independent reviews that were conducted in 2015-2016. It also looks at the actions taken and progress made to address the main concerns and recommendations from the reviews.

2 Our investigation focused on the new contract management arrangements and the relationships of the commissioning bodies, the Home Office and NHS England, with their contractors, Serco and G4S. It looked at the extent to which these were a factor in criticisms of Yarl’s Wood, specifically those arising from the various reviews.

3 This report provides:

An introduction to the immigration detention estate and to Yarl’s Wood in particular, including details of the contracts under which Serco and G4S run the centre – it also sets out the common areas of concern identified by the different reviews.

Analysis of the issues raised by the different reviews of residential services and residents’ feedback, the extent to which they were covered by the contracting process, and progress in implementing the reviews’ recommendations.

Analysis of the issues raised by the reviews about healthcare services, the extent to which they were covered by the contracting process, and progress in implementing the reviews’ recommendations.

4 Our work does not assess the value for money of the Yarl’s Wood contracts or the quality of services.

Methods

5 In examining these issues, we drew on a variety of evidence sources.

6 We interviewed relevant individuals from the contractors Serco and G4S, as well as people from the Home Office and NHS England responsible for managing the contracts. We also visited the Immigration Removal Centre on two occasions and spoke with staff and management. The people we interviewed included:

members of the procurement, commercial and immigration enforcement policy teams in the Home Office and the operational team based in Yarl’s Wood;

members of the commissioning team responsible for Yarl’s Wood and those involved more broadly in immigration removal centre procurement and policy in NHS England;

the centre manager and members of the Serco senior management team at Yarl’s Wood;

representatives from G4S involved in providing and managing healthcare services; and

two representatives from the Yarl’s Wood Independent Monitoring Board.

7 We reviewed a range of documentation:

Home Office guidance and statistics on detention;

inspection reports and independent reviews;

procurement and contractual documents for the G4S and Serco contracts;

minutes of monitoring meetings and a selection of assurance and partnership boards; and

management reports and policies produced by both G4S and Serco.

Design and Production by NAO External Relations
DP Ref: 11011-001