EPAHTMENT OF ARA POUTAMA AOTEAROA 31;. . . tn .- lzi' l; . .1 . 19 June 2018 095840 8 9 (2X8) Dear 9 Thank you for your email of 6 May 2018 requesting information about Corrections review of the Cell Sharing Risk Assessment. Your request has been considered under the Official Information Act 1982 In response to incidents that identified prisoner safety may have been compromised by the policy or practice of the Shared Accommodation Cell Risk Assessment (SACRA) process, Corrections Deputy Chief Executive Jeremy Lightfoot directed the Chief Custodial Officer to undertake a review of the SACRA process. The review found that these incidents were not the result of a systemic failing of the SACRA process and the root cause of the problem was determined to be staff performance failure. The review also found that the current SACRA policy was achieving its intended purpose, which is to reduce the level of risk prisoners may pose to each other when placed in shared accommodation cells. The review did identify that there was a lack of consistency and accountability in the application of SACRA in various parts of the prison estate. As soon as this became apparent, Regional Commissioners were made aware of the data provided by the review and immediately put in action plans to address the concerns. Staff have been advised of the importance of completing SACRA assessments in a timely manner. For December 2017, 96.15 percent of SACRA assessments were completed on time. This is a significant improvement on the period covered by the review, which showed between 74.96 percent and 78.87 percent of SACRA assessments for the period 1 June to 31 August 2017 for 18 prisons had been completed on time. As described in the report and the Letter to the Chief Custodial Officer from me (Appendix 6), many of these assessments that were described as ?completed late? were completed ?on paper? and within minutes of the electronic cell allocation. In practice, this means the assessment still occurred before the prisoners are physically located in the cell together. NATIONAL OFFICE, WELLINGTON Mayfair House, 44-52 The Terrace, Wellington 6011 Private Bag 1206, Wellington 6140 phone +64 4 460 3000 fax +64 4 460 3263 :0 A copy of the final report dated 7 November 2017 is attached. I trust this information is useful. If you have any concerns with this response, I would encourage you to raise these with Corrections. Alternatively you are advised of your right to also raise any concerns with the Office of the Ombudsman. Contact details are: Office of the Ombudsman, PO Box 10152, Wellington 6143. Yours sincerely yaw? Rachel Leota National Commissioner DEPARTMENT 0F 3, - IN CONFIDENCE - -.rM Fifi-1:7 Operational Review Date: 7 November 2017 Prepared By: Richard Symonds, Chief Custodial Officer (Acting) Review Commissioner: Jeremy Lightfoot, Deputy Chief Executive (Acting) Review of the Shared Accommodation Cell Risk Assessment (SACRA) process IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document. This report is forwarded to external agencies under the provisions of section 6, principle 11 of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention. detection. investigation, prosecution, and punishment of offencesErrorl Unknown document property name. TABLE OF CONTENTS EXECUTIVE SUMMARY 3 PURPOSE 4 BACKGROUND 4 SCOPE OF REVIEW 5 METHODOLOGY REVIEW PROCESS 5 FINDINGS 6 Environment 6 International best practice 6 Practice Frameworks and Policies 8 Compliance with policy 9 Alerts 11 Complaints 13 People 13 Staff understanding 13 Prison Director feedback 14 Prisoner feedback 15 Tools and Resources 16 Training 16 Legacy IOMS 17 CONCLUSION 17 RECOMMENDATIONS 19 SIGN OFF 20 APPENDICES 20 IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency. including the prevention, detection, investigation, prosecution, and punishment of offences. 3 EXECUTIVE SUMMARY The review of the Shared Accommodation Cell Risk Assessment (SACRA) process was commissioned to ensure it is fit for purpose in response to recent incidents that have identified prisoner safety may have been compromised by the policy or practice of SACRA. Some prison sites were visited and other regional staff contacted to seek custodial feedback about their understanding of the policy, training received, site practices and suggestions for improvement from staff and prisoners. Policy and practices in the United Kingdom (UK) and Australia were also canvassed for comparison and international best practices. The policy for SACRA in the Prison Operations Manual (POM) aligns with the Chief Executive?s instructions on shared cells issued under the Corrections Act 2004 and establishes the minimum requirements for current shared cell accommodation (?double bunking?). As demonstrated by data available from the new COBRA dashboard ?12.1 Custodial Standards of Practice Shared Accommodation Cell Risk Assessment some practices were impacting on compliance with policy. The data was provided to Regional Commissioners and action plans were implemented to address the immediate compliance issues identified by this review. The full response and outcome is detailed in the letter to the Chief Custodial Officer from the National Commissioner dated 17 October 2017 and attached as an appendix. It has also been identified that other operational systems and resources, such as the ?Alerts? system, the Integrated Offender Management System (IOMS) and training, could strengthen the risk assessment and recommendations are made to reflect this. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 4 PURPOSE 1 The purpose of this review is to report on the SACRA process and whether it is meeting its intended purpose to reduce the level of risk prisoners may pose to each other when placed in shared accommodation cells i.e. ?double bunked?. BACKGROUND 2 In 2008/09 the Crown Law Office raised concerns about the lack of a formal process for assessing the suitability of prisoner placement in a shared cell. in addition, a previous judgement in the United Kingdom regarding the murder of a prisoner by his cell mate found Her Majesty?s Prison Service was in breach of Article 2 of the Human Rights Act, in that it failed to have in place an adequate risk assessment procedure. 3 In response the Department designed and implemented the Shared Accommodation Cell Risk Assessment (SACRA) process. its purpose was to reduce the level of risk prisoners pose to each other when placed in shared accommodation by ensuring an objective and auditable assessment has been made on the suitability of prisoners in shared cells. 4 Recent incidents have made evident that the SACRA process has not always been followed as per policy, or despite being followed, still compromised prisoner safety in some instances. 5 A preliminary review of the circumstances relating to the shared cell placement of a violent sexual offender was undertaken in December 2016 and no systemic failing of the SACRA process was identified. The root cause of the problem was determined to be a staff performance failure and the inappropriate deactivation of the ?Not to Double Bunk? (NTDB) alert in the integrated Offender Management System (IOMS). 6 Subsequently, an email was sent to all Prison Directors on 24 February 2017, seeking recommendations on how the SACRA process could be made more robust. It requested discussion with their key staff at the respective sites, and advised that any feedback received would be considered in the development of any SACRA training that may be developed in the future. 7 A Frontline article was published 27 February 20171 to all prison staff requesting they familiarise themselves with the SACRA process as described in the Prison Operations Manual and stipulated the deactivation of any key alerts must never occur in order to facilitate the compatibility of prisoners assessed under SACRA. 1 See Appendix One, Frontline article 27 February 2017, available at data/assets/pdf 2.0 27 February to 5 March 2017.9df (last accessed 24 September 2017) IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(6) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. SCOPE OF REVIEW 8 10 This review will determine and report on whether the SACRA process is being managed according to required policy, is understood by staff and appropriately integrates with the wider operations and safe management of prisoners. In addition, it will report on whether the SACRA is meeting international best practice and where any potential improvements can be made. This will include how the Department can best ensure that staff fully understand and properly implement the process, incorporating an assessment of the training provided to staff in relation to the SACRA. To make such recommendations, for the improvement of promulgated standards, procedures, operating systems, work practices and risk controls as may be necessary. REVIEW PROCESS 11 12 13 14 15 16 Four sites were visited by two members of the Chief Custodial Officer?s (000) team. They were chosen to include the lowest and highest achieving sites identified from the ?Prison Standards of Practice Shared Accommodation Cell Risk Assessment COBRA report, one women?s prison and one other large prison. The prisons visited between 13 and 18 September 2017 were: Hawkes Bay Regional Prison (HBRP) Mt Eden Corrections Facility (MECF) Auckland Region Women's Corrections Facility (ARWCF) Rimutaka Prison. The site reviews were completed over one day at each site and included: . Interviews with custodial staff at all levels (approximately 28 staff) 0 Interviews with prisoners individually (12 male, 7 female). To supplement the interviews conducted by the CC0 staff, Regional Director?s Practice Delivery were contacted to provide additional feedback from prisons in the two regions not visited.2 Responses were received from: . Christchurch Men's Prison (14 staff, six prisoners) . Spring Hill Corrections Facility (15 staff, 12 prisoners) . Waikeria Prison (nine staff, 19 prisoners). In total, approximately 66 staff and 56 prisoners were interviewed. 2 See Appendix Two for the questions sent for response from custodial staff and prisoners. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(3) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 17 Eighteen Prison Directors were contacted for feedback.8 18 Process documentation and practice information was directly sought from Her Majesty?s Prison and Probation Service (United Kingdom), Corrective Services - New South Wales Government and Corrections Victoria (Australia). 19 External research was sought regarding international best practice. FINDINGS Environment 20 As at 31 August 2017, 41 percent of prisoners were sharing a cell in New Zealand prisons. 21 As part of our short and longer term building programme we have added extra capacity at Hawkes Bay, Arohata, Christchurch Men?s, Mount Eden, Whanganui, Northland and Waikeria prisons through double bunking, reopening units and bringing New Plymouth remand centre onto capacity. The deployment of three sets of 120 prisoner place modular units; two at Rolleston and one at Tongariro, and the large developments planned at Mt Eden Corrections Facility and Waikeria Prison all incorporate double bunking facilities. 22 Increased double?bunking, in manageable numbers, has proved to be a practical and cost effective solution to provide immediate accommodation for prisoners. Increases in double?bunking have been implemented by increasing staffing levels and supporting infrastructure accordingly. Corrections? operational procedures also support the safe, secure and humane use of double?bunking,4 including, but not limited to, the SACRA. 23 The SACRA design was based on international best practice, particularly derived from the policy in the United Kingdom, and still compares favourably to current international policies and practices. International best practice United Kingdom (UK) 24 Currently, Her Majesty?s Prison and Probation Service (formerly the National Offender Management System) utilise the 41?page ?Cell Sharing Risk Assessment? instruction PS 20/2015.5 3 Ibid, for the questions sent to the Prison Directors for response. 4 The Department of Corrections Strategy, Policy and Planning Prisoner double?bunking: Perceptions and impacts; Findings from a two-phase research investigation, (April 2012) available at and statistics/prisoner double- bunkinq perceptions and impacts 2012.html found that so long as double bunking was carried outwith good practice, processes and systems in place, there was no additional threat to prisoner or staff safety (last accessed 24 September 2017). 5 See 20 2015 Cell Sharlnq.pdf (last accessed 21 September 2017) IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonivarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 25 26 27 28 29 30 The instruction states ?the CSRA is an essential tool in the identification of prisoners at risk of seriously assaulting or killing a cell mate in a locked cell?.6 Similar to the SACRA, it is intended to be based on the latest information and to support staffjudgement about cell allocation but not to replace staffjudgement, provide an actuarial risk score or rule out cell sharing by prisoners who pose a risk. One comparable difference to the SACRA is the requirement for ?every prisoner held in closed conditions [to] have an up to date Cell Sharing Risk Assessment, even where there is no shared accommodation.? The aim of the CSRA is to assess the risk posed by one prisoner to another in any unsupervised closed space, including locked cells. Another difference is the policy determination that a small number of prisoners are deemed to be ?mandatory high risk prisoners? because they have committed offences which are so significant in cell sharing risk terms, they should always be initially categorised as high risk. The offences are: Murder or manslaughter of another prisoner Assisting in the suicide of another prisoner Committing a life threatening assault on another prisoner Raping or committing a serious sexual assault on an adult victim of the same sex 0 For Young People only (aged 15 to 17) the victim may be any age and either male or female.8 Notably, even the risk rating of the prisoners who have committed these offences can be downgraded based on an evidenced reduction in risk. Anecdotal feedback about custodial practice in the UK referred to non- standardised quality assurance practices and personnel nominated to check outstanding CSRAs daily. Australia 31 Corrections Victoria Feedback from the Operations Directorate relating to the Deputy Commissioner's Instructions (DCI) regarding prisoner placement and reviews confirmed there is no template completion required to capture the considerations of staff determining shared cell compatibility. An entry in the system comparable to IOIVIS is required and compliance reviews can be undertaken by senior prison management. The feedback specifically advised "we also place some trust in staf and aligns with the intent of the SACRA, in part, to support staffjudgement. 6 Ibid, 'Operational Instructions', page 3. 7 Ibid, ?Purpose', page 4. 8 Ibid, ?Risk Categories?, page 5. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonrvarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency. including the prevention, detection, investigation, prosecution, and punishment of offences. . Corrective Services New South Wales (NSW) 32 ?Section 7.17 Inmate Accommodation? of the Operations Procedures Manual details considerations and policy requirements for assessing cell sharing. The NSW government made regulatory changes in 2016 permitting two prisoners to a cell, and even two-person cells being used to accommodate three prisoners. In January 2017, it was reported that assaults on prison premises had increased by 37 per cent over the past two years. Considering their current prison capacity has been exceeded, and is impacting on their practice, NSW has not been further researched for potential best practices regarding cell shanng. Practice Frameworks and Policies 33 The policy for SACRA in the Prison Operations Manual (POM), [.08 Shared Accommodation Cell Risk Assessment,9 aligns with the Chief Executive?s instructions on shared cells effective 1 December 201010 issued under section 196(1)(b)(i) of the Corrections Act 2004 (CE instructions). 34 The CE instructions ?establish[ed] the minimum requirements for the safe, secure, humane and effective containment of prisoners in shared occupancy cells necessary for the Department to be able to use shared occupancy cells under regulation 35 The policy derived from these instructions is supplemented by l.08.Res.01 SACRA compatibility guidelines? (compatibility guidelines), which are reflected, in part, in the l.08.Form.01 Shared accommodation cell risk assessment (SACRA report) that is completed in IOMS. 36 In summary, current policy requirements are: . Complete an IOMS SACRA report for prisoners required to share a cell - Prisoners must be assessed using the SACRA process before being placed in a shared accommodation cell, preferably by custodial staff rostered in the unit/wing where the prisoners will be placed . Both prisoners must be reviewed for compatibility before placement with reference to the SACRA report and the compatibility guidelines . The resources provided serve as a guide only and do not replace staff judgement at the time of assessment . If a prisoner is assessed as not suitable to be placed in shared accommodation, a NTDB alert must be entered in IOMS. . If relevant information becomes known to staff at a later date that may impact on the prisoner's placement, their placement must be immediately reviewed. 9 See Cell-RiSk-Assessment (last accessed 24 September 2017) 10 See Appendix Three for the ?Chief Executive?s instructions on Shared Cells?. 11 See ?Frequently asked questions about Chief Executive?s instructions on Cell Sharing' at data/assets/pdf nstructions-on-celI-sharinq?1 71 1 10.pdf (last accessed 24 September 2017) 12 See Appendix Four, available at data/assets/pdf (last accessed 28 September 2017) IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonNarded to external agencies under the provisions of section 6, Principle 11(9) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 37 38 39 40 Accounting for the recent incidents identified, the compatibility guidelines include specific reference to sexual/violent ?Offending History? by directing staff to consider, among other things: How vulnerable is the prisoner likely to be based on age, offending history, offence type, and experience in any form of custody? Additionally, other factors include reference to ?Sex Offender? and a consideration of whether they are at high risk of harm if placed with mainstream prisoners (child sex offenders) and to consider if they could be placed with another sex offender if safe to do so. In total, 19 ?other factors? and related considerations are detailed for staff to refer to when assessing the compatibility of prisoners to share a cell. Taken in their totality, they are an expansive assessment of potential risk factors that support staff to make professional judgements when assessing prisoner compatibility. Note the only mandatory compatibility directives relate to security classifications, youth, segregated and transgender prisoners. The current design and application of the SACRA acknowledges and incorporates staffjudgement, on a case by case basis, and supports professional decision making; there was no available evidence that staff decisions are a systemic issue that are increasing risks to prisoners. Compliance with policy 41 42 43 44 Available to all custodial staff from 7 September 2017, the new COBRA dashboard ?12.1 Custodial Standards of Practice Shared Accommodation Cell Risk Assessment provides data about the timeliness and completion of SACRA across the estate. The purpose of this Standard of Practice is to ensure the timeliness of the Shared Accommodation Cell Risk Assessment (SACRA), with the aim of reducing the level of risk prisoners pose to each other when placed in shared accommodation cells. The current assurance tool that sites use to report SACRA compliance is the quarterly Checkpoint report. The Prison Directors utilise information from the current first line of defence assurance tools on their site to complete the survey. Checkpoint includes a request for assurance regarding SACRA, as below: I give assurance that all prisoners sharing a cell have a SACRA completed before placement in a shared cell. Prior to the development of the new dashboard, the assurance provided by manual reporting to Prison Directors was insufficient to robustly capture SACRA practices in individual prisons. Residential Managers were made aware of the new dashboard and advised to communicate this to all Principal Corrections Officers and Senior Corrections Officers by a member of the Chief Custodial Officer?s team. It was apparent from the site visits, and responses from two Prison Directors, that the existence and availability of the dashboard was not well known at the IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 10 time. See the tables below for data extracted from the dashboard13 for the period 1 June to 31 August 2017 across the estate. Table 1.1 SACRA assessments for the period 1 June to 31 August 2017 for 18 prisons? ?hg?a'ng?t?ltw 0.. time}. g1; Date Late+ time Started ?June 2017 78.87% 843 4494 361 5698 July 2017 74.96% 965 3903 339 5207 ~August 2017 76.28% 1080 4648 365 6093 Grand Total 2888 7? 13045 1065 16998 45 Feedback from some staff illustrated a misinterpretation of policy timeframes that would impact adversely on site performance. it was not uncommon for staff to advise they would document the completed IOMS SACRA within their rostered shift, as one of the operational requirements they are subject to, instead of the policy requirement to complete SACRA before they are placed in a shared cell. 46 The ?completed late? data includes all SACRAs processed in IOMS after electronic cell allocation and it is apparent from manual review of the late data that many of them are completed within minutes of the ?cell sharing started? (cell allocation) action; this could be interpreted as evidence of sequential processing errors. 47 Site practices differed but some practices identified during the review period induded: completing SACRA within 24 hours of cell placement . "when possible", dependent on staff availability . more experienced staff being tasked with the assessment to maximise the input of staff knowledge . the use of templated text to enter in the SACRA assessment to provide the commentary required in IOMS 0 use of tactical communications by staff to facilitate prisoner acquiescence to cell sharing . active management of cell sharing arrangements determined by gang affiliation . attempts by staff to ensure discussion with, and introduction of, prisoners prior to completing a SACRA 13 'Completed on Time': SACRA created from 4 hours before cell sharing commenced up to the time that cell sharing commenced. 'Completed Late': SACRA created after cell sharing commenced but within 24 hours from the time cell sharing commenced. 'Not Started': SACRA created more than 4 hours before cell sharing commenced or SACRA created more than 24 hours after cell sharing commenced or SACRA not created at all. 14 Auckland Prison, Tongariro Prison, Rolleston Prison, and Christchurch Women's Prison were not ?double bunking' during this period. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonNarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 11 - attempts to place prisoners in shared cells before the end of the day shift so late arrivals could be placed in single cells . a nominated resource, the ?Prisoner Placement Officer?, responsible for actioning SACRAs in the Receiving Office to ensure standardisation and compliance with policy requirements (Mt Eden Corrections Facility 48 Additional non?standardised SACRA compliance checks and risk controls identified during the review included: . Sample checks coordinated by the Practice Manager Custodial from at least two sites in the Central region undertaken in April, May, June, and July 2017, reviewing practice and compatibility of prisoners . Use of unit logbooks to record reports have been completed (MECF, Hawkes Bay Regional Prison and Auckland South Corrections Facility and movement towards having this information attached to the daily tension tool from each area (ASCF) 0 Principal Corrections Officer (PCO) requests for reports to be printed for manual review . Security Manager review of reports to ensure compatibility. 49 Although there were obvious attempts of varying value to monitor compliance and review staffjudgements about prisoner cell sharing compatibility, there was a lack of consistency and accountability identified. 50 The Regional Commissioners were made aware of the data provided in this paper and immediately put action plans into place to address the highlighted concerns. Alerts 51 As per POM policy /.08.05 Prisoners assessed as not suitable to be placed in shared accommodation, staff are specifically directed to enter a NTDB alert when a prisoner is assessed as not suitable. 52 No other guidance or directive is explicitly provided to staff to categorically determine a prisoner is ?not suitable? and there are no risk variables, such as prior offending in custody, that trigger a mandatory requirement to enter a NTDB alert. Feedback from staff identified some confusion about who should be entering alerts, whether they were even allowed to and in what circumstances they were obligated to do so. 53 Conversely, oven/vhelming staff feedback during site visits was the fundamental importance of reference to active alerts when assessing a prisoner's risk for cell sharing, most notably the NTDB alert. 54 The NTDB alert was made available during the SACRA pilot in April 2007; 732 have been entered to date15 and 261 were active for offenders in custody of a total muster of 10,512 as at 25 September 2017.16 15 As at 25 September 2017. ?3 lbid. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonNarded to external agencies under the provisions of section 6, Principle 11(9) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 12 55 Considering the throughput of prisoners for the financial year 2016/17 alone was 24,443,17 a very small number of prisoners have been deemed ?not suitable? to share a cell since April 2007. 56 This may demonstrate the robustness of the SACRA to assess compatibility and manage placement or infer staff are hesitant to utilise the NTDB alert; no determinant can be extracted from Departmental systems to evidence the reason for the number of NTDB alerts entered to date. 57 Other directives for entering alerts, such as the transgender alert,18 are distributed throughout POM but there is no single guidance document about who can, or should, enter alerts in IOMS and under what circumstances. 58 A preliminary review commissioned by the Chief Custodial Officer of the IOMS alerts system more generally has identified a number of issues relating to how staff understand and use the system. The volume of alert types, which has increased to 68 without any guidelines for reference, seems to be causing confusion among staff that is potentially a risk. A paper is being drafted to seek approval to conduct a more detailed review and restructure of the alerts system to more effectively manage the risk identified. 59 In the interim, the deactivation of alerts process for eight alerts deemed ?key?, including NTDB, was formalised and published in the Frontline article published 27 February 2017 for all custodial staff:1g Deactivation of any of the above key alerts must never occur in order to facilitate the compatibility of prisoners assessed under SACRA. Any deactivation of key alerts should be carefully considered and only occur following consultation with the Principal Corrections Oh?icer or Residential Manager of the unit in which the prisoner(s) are to be accommodated. 60 To further mitigate the risk identified, Prison Circular ?2017/01 Directive to Manage Prisoner Alerts on was issued as a permanent instruction on 17 August 2017 with the purpose of defining: is responsible for the management of IOMS Alerts to ensure accountability for the accuracy, timeliness and applicability of any information regarding a prisoner that warrants an Alert being activated on IOMS. 61 The Circular directed that only PCOs are to de-activate any IOMS Alert generated for a prisoner and they are to check all prisoner alerts on reception into their unit to ensure they are applicable, current and accurate. It was 17 Regarding prisoner throughput data, it is important to note the number contains both sentenced and remand prisoners, and will include some offenders more than once in each offender status. Note also that if a remand prisoner is cell sharing, they will require a review of placement, and potentially another SACRA, when they are remand convicted or sentenced. 18 See M. 03. 05.01 Initial determination of prisoner?s placement at (last accessed 24 September 2017) Wee Appendix One, available at data/assets/pdf 2.0 27 February to 5 March 2017.pdf (last accessed 24 September 2017) Available at circulars/201701 directive to manage prisoner alerts on ioms (last accessed 27 September 2017) IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions ofsection 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 62 63 13 directed that duplicate alerts should be consolidated into one alert and multiple alerts of the same nature should be managed as one alert. An immediate alert review was required to fulfil the directive and all Regional Commissioners subsequently confirmed the completion of the review. There was general comprehension of this limitation to deactivating alerts among staff interviewed, although it would engender a manual review of all key alerts deactivated since this date to determine compliance with the recent directive. Overall, there was encouraging feedback from staff that they were confident to escalate any concerns about a prisoner?s cell sharing risk and/or discuss the need for an appropriate alert to be entered by higher ranked staff. Complaints 64 65 66 67 People In accordance with the CE instructions, the SACRA POM policy section l.08.08 Prisoner Complaints explicitly refers to managing complaints regarding cell placement through the POM prisoner complaints process. Current reporting capabilities cannot provide data, either through the P001 complaint entries in IOMS, or the secondary Complaints Response Desk resolution option to quantify or qualify prisoners? complaints about cell sharing, or the reasons for the complaints. Nevertheless, the provision of the complaints process, and access to external complaint hearers, such as the Inspectors and the Ombudsman, are a robust Departmental system to enable prisoners to raise issues as required. Varying levels of confidence were expressed by prisoners interviewed about issues with cell mates being addressed if they approached staff but generally they reported staff were responsive if they requested to move. It was apparent that, due to a high number of movements and the increasing muster, there was a high turnover of cell mates and this may be mitigating relationship issues that would otherwise become problematic. Staff understanding 68 69 Discussions and feedback from staff illustrated an understanding of the intent of the SACRA and its importance as an operational requirement. Although this feedback was not fully supported by the data available, the general practice across sites of tasking more experienced staff with the process is interpreted as an acknowledgement of their greater capability to utilise staff knowledge and judgement. It was widely reported that staff knowledge of individual prisoners is fundamental to the quality of the risk assessment and that the current policy and process enables their capacity to use their professional judgement. 21 See Prisoner complaints at (last accessed 24 September 2017) IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonrvarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 7O 71 72 73 14 The assessment is considered to be of more limited value when new staff action the policy or when new prisoners, with no custodial history, have to be assessed with less information, if any, available. Staff reported these potential risks are mitigated, in part, by discussions with more experienced staff and the prisoners individually. A particular concern expressed by staff about their capacity to fulfil SACRA policy requirements was when prisoners were received after hours. These circumstances provided less capacity for staff to discuss cell placements with both prisoners prior to placement, less access to staff knowledge due to the reduced staff numbers, other competing processing requirements and less capability to make multiple prisoner movements if required to more appropriately place a prisoner in a shared cell. A frustration articulated by staff was the ?domino effect? SACRA assessments could have on cell allocations; to ensure the compatibility of prisoners sharing cells could necessitate up to six movements. Although obviously frustrating for staff, this is perhaps more a reflection of the considered staffjudgements that are being employed to ensure risk is minimised. Overall, staff tasked with completing SACRAs expressed confidence in using the current decision framework supported by the compatibility guidelines and did not identify any policy or administrative changes that could improve the assessment of risk. Prison Director feedback 74 75 76 All Prison Directors were emailed fortheir input,22 the responses received included: 0 No concerns with the current policy or process (two) . The experience and capability of the staff member actioning the assessment determines its quality . The current assurance process [Checkpoint] does not provide for quality . Two requests for a SACRA data report (the link to the new Standards of Practice SACRA report was fonrvarded in response) . Requests for further staff training to ensure they understand why SACRAs need to completed to a high standard and confidence in making decisions . A suggestion that a flow chart model may be a useful resource to drive decision making - References to similar assurance processes to complete the Checkpoint survey quarterly and some non-standardised monitoring activities. Generally, the lack of quality controls over SACRA decisions was highlighted as a facet of the decision framework that could be addressed to improve safety. Notably, increasing the administrative accountability, such as requiring additional template information or sign off, was absent from the Prison Directors suggestions for improvement; staff understanding of the intent of the SACRA was communicated as the fundamental dependency. 22 See Appendix Two for the questions sent to the Prison Directors for response. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonivarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 15 Prisoner feedback Considering the concern expressed by staff about receiving prisoners after hours, the review team asked prisoners what time they had been received to the prison. Although a very limited amount of interviews contributed to the observation, it was apparent their experience of cell placement markedly differed from other prisoners interviewed who had been received during the day shift. Predominantly placed in a cell that already had an occupant, there was no prior discussion (or introduction) before their physical entry to the cell about their potential compatibility. Some prisoners reported their placement was subsequently reviewed within the next few days or they reported issues to the staff about their cell mate that facilitated their movement. Confidence in requesting staff review their cell placement varied between units and prisons; some prisoners alerted the reviewers to the risks more submissive prisoners were subject to if they weren?t confident to alert staff to issues with cell mates. Nevertheless, all prisoners seemed to be confident that a major incident with a cell mate would be immediately addressed by staff. Generally, though dependent on the relationships with unit staff, prisoners would identify other prisoners they would prefer to share a cell with and request to move. There was a general perceptible resignation among prisoners interviewed that ?this is prison" and therefore you could not have an expectation you would get a single cell. Discussion about how their own risk mitigation tactics were employed to get along with their cell mate demonstrated real effort on behalf of some prisoners to minimise issues without involving staff. Suggestions from prisoners for minimising risks between cell mates included mandatory cell movement after a period of time (so one cell mate could not accuse another of requesting to move), regular private meetings with a staff member to provide an opportunity to discuss issues they would not raise in the unit, longer unlock hours and more activities outside the cell. Ovenrvhelmingly prisoners, and staff, reported that side by side beds in shared cells relieved much of the tension as no one was relegated to the top bunk. In addition, a slight majority of prisoners interviewed stated they would prefer single cells, but were prepared to manage in a shared cell, and some expressed a preference for cell sharing, primarily to relieve the boredom.23 23 See Strategy, Policy and Planning Prisoner double-bunking: Perceptions and impacts; Findings from a two- phase research investigation, April 2012 available at resources/ research and statistics/ prisoner double? bunkinCl perceptions and impacts 2012.htm (last accessed 24 September 2017) for a more detailed study of double bunking, including prisoner feedback. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonrvarcled to external agencies under the provisions of section 6, Principle 11(6) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public Sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 16 Tools and Resources Training Currently the training available to Corrections staff is delivered at the National Learning Centre during Phase Two: Safety and Security of the Corrections Officer Development Pathway (CODP). The objectives of the training are for staff to be able to: 0 describe SACRA policy . apply the SACRA compatibility guidelines tool to assess the risk of placing prisoners in a shared cell . enter SACRA data on A training facilitator guide?4 a PowerPoint presentation, and eight scenarios are the resources available to deliver SACRA training in approximately 45 minutes. This is not a topic that is currently refreshed on a regular basis however, new documentation has recently been drafted for SACRA training delivery, pending approval, but there are no substantive changes to the information. Feedback from staff during the review was mixed about the training received. It is not uncommon for staff to report they recall some training on a topic delivered during their initial training phase but their recollection is not detailed enough to claim it was ?useful?. Generally staff advised they were trained one on one by more experienced custodial staff to become familiar and confident with the SACRA process and making decisions about placement. There was an acknowledgement that experience in the custodial environment and knowledge of prisoners were the most important factors in actioning quality risk assessments for shared cell placement. Staff self-reported that more facilitated training would assist them to use the SACRA process confidently and staff who had been working in custodial positions for longer periods of time did not recall any training at all. There was general support for additional facilitated training, including the perception that this mode of delivery made them feel ?invested in? by the Department. The SACRA timeliness and completion data presented in this paper infers the policy regarding SACRA being processed before placement in all circumstances is not well enough understood by all custodial staff to be a driver of operational practice. The absence of any readily available on?site refresher training identified, particularly for staff who may have been working in facilities that have only commenced, or increased, their double bunking capacity in the last few years, is potentially a training deficiency that needs review. Auckland South Corrections Facility (ASCF) has confirmed they will be scheduling SACRA refresher training for all staff and this will include formal 24 See Appendix Five, for the current facilitator training guide. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 94 17 competency assessment for sign off by the training manager to improve compliance and understanding. For Corrections staff, all of the CODP content is also scheduled to go online for reference and the pending Frontline Learning Hub will make the refreshed content available and trackable to confirm staff completion. Legacy 95 96 97 98 99 100 101 102 103 Parallel to self-reported deficiencies in SACRA training, staff were discussing some of the issues they were having adopting the use of the new Web platform with minimal to no training. it was identified that staff could ?drag and drop? prisoners into cells electronically via Legacy IOMS to allocate their placement. This meant completing the SACRA report could be circumvented by the electronic capacity to allocate a prisoner to a cell. The subsequent completion of the report would be captured as ?completed Iate?. Although the new Web IOMS platform does not have the capacity to ?drag and drop? prisoners this way, it does not electronically enforce the completion of the SACRA report prior to cell allocation. There is a prompt to alert staff that a SACRA has not been completed but this can be overridden and the cell allocation completed. CONCLUSION The current SACRA policy aligns with the relevant legislation and does not require amending to meet its intended purpose to reduce the level of risk prisoners may pose to each other when placed in shared accommodation cells. Current practices being used to fulfil SACRA policy requirements differ across the estate. Further review of the current compatibility guidelines to ensure they provide for all relevant considerations could potentially increase their value. A lack of written guidance about when a NTDB, or other high risk, alert should be considered mandatory is potentially the weakness of the current policy. The provision to all custodial staff of the new ?Prison Standards of Practice Shared Accommodation Cell Risk Assessment COBRA report from 7 September 2017 equips staff with a robust reporting tool to monitor SACRA compliance. Compliance with completing SACRA before shared cell placement could potentially be enforced with a technical solution through Web IOMS and requires further investigation. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 104 105 106 107 18 The lack of reporting capability to monitor the quality of SACRA assessments, such as cross referencing incident reports, is a deficiency that impedes the visibility of potential practice failures. Staff self?reported training deficiencies in SACRA process, policy and Web IOMS. Although no systemic issue relating to staff decision making for shared cell placement was identified, most notably because more experienced staff are tasked with the SACRA, additional training may increase the quality of the risk assessments. A lack of meaningful notes entered into the SACRA assessment to provide a record for future reference about the risk variables considered devalues the assessment and infers a lack of staff understanding about their importance. Further research into international best practice could be of value in identifying processes and practices that could not be adequately researched for this review. IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is fonNarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 19 RECOMMENDATIONS Note the contents of this review, that a draft copy of the review was provided to the National Commissioner and that the National Commissioner's response is attached Yelo b) Agree the National Commissioner will monitor the improvement in performance generated by the Regional Commissioners? action plans Agree to the compilation of guidance on the use of the ?Not to Double Bunk? alert to staff for approval and distribution d) Agree to task the Chief Custodial Officer to conduct a more detailed review and restructure of the alerts system to more effectively manage the ris identified with a lack of guidance (- IWACUK W1M (BBAMQK vaf-KU wv EL Visas-.31 Agree to scope the potential for a Web IOMS solution that necessitates SACRA completion prior to cell allocation to resolve the timeliness and completion issues f) Agree that Learning and Development review and address current staff training requirements to ensure SACRAs are completed to a high standard and to support staff decision making IN CONFIDENCE This document is an CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention, detection, investigation, prosecution, and punishment of offences. 20 SIGN OFF Approved By: (Review Commissioner) rainfall? Jeremy Lightfoot Deputy Chief Executive (Acting) (Date) APPENDICES Appendix One: Appendix Two: Appendix Three: Appendix Four: Appendix Five: Appendix Six: Front/inc article published Monday 27 February 2017 Questions sent for response from custodial staff, prisoners and Prison Directors Chief Executive?s instructions on Shared Cells I. O8.Res.01 SA CRA compatibility guidelines SA CRA Facilitator Guide Letter to the Chief Custodial Officer from the National Commissioner IN CONFIDENCE This document is an IN CONFIDENCE Department of Corrections document: This report is forwarded to external agencies under the provisions of section 6, Principle 11(e) of the Privacy Act 1993 to avoid prejudice to the maintenance of the law by any public sector agency, including the prevention. detection, investigation, prosecution, and punishment of offences. Appendix One: Frontline article published Monday 27 February 2017. Shared Accommodation Risk Assessment (SACRA) To: All prison staff. From: Corrections Services, National Office. When: Immediate. In short: The purpose of the Shared Accommodation Cell Risk Assessment (SACRA) is to reduce the level of risk prisoners may pose to each other when placed in shared accommodation cells is double bunked. When conducting a SACRA, staff should access all relevant information on the compatibility of a prisoner and not solely rely on the results of the IOMS SACRA report to identify potential risks to a prisoner?s placement. Action: Staff are to action the following Familiarise themselves with the SACRA process as described in the Prison Operations Manual Cell-Risk-Assessment Staff should also familiarise themselves with the various locations where additional relevant information is stored on IOMS. This can assist in the robust assessment of risk and further aid in the determining of the suitability and compatibility of prisoners and their placement. These may include but are not limited to the following:- l.08.Form.01 SACRA Report .08.Res. 01 SACRA Compatibility guidelines IOMS Alerts IOMS File notes SDAC (Structured Dynamic Assessment Case-management) SACRA compatibility guidelines serve only as a guide and do not replace staff judgement based on the information available at the time of assessment. If at any stage staff become aware of additional information that may impact on a prisoner?s placement. their placement must be immediately reviewed. Particular attention should be paid to alerts such as:- . NTDB Non Association Aggression Threat to Others Forensic Concerns Assault Sexual Risk of Suicide Risk of Self Harm Deactivation of any of the above key alerts must never occur in order to facilitate the compatibility of prisoners assessed under SACRA. Any deactivation of key alerts should be carefully considered and only occur following consultation with the Principal Corrections Officer or Residential Manager of the unit in which the prisoner(s) are to be accommodated. Department of Corrections SACRA Review 2017: Appendix One data/assels/pdf Contact: If you have any questions, please contact 59(2)(a) Senior Practice Adviser (ext: 59(2llai) or via email: mailto: sQ(2)(a) Approved by: Christopher Lightbown. Acting Chief Custodial Officer. Department of Corrections SACRA Review 2017: Appendix One Appendix Two: Questions sent for response from custodial staff, prisoners and Prison Directors To custodial staff who action SACRA: Does the current policy add value to the safety and security of the prison? Are you confident the current policy is sufficiently robust, or have any suggested changes? What is the practice/process of actioning a SA ORA at the prison? For example, movement from R0 to unit; discussion with prisoners; checks etc To prisoners: What discussions did you have with staff about sharing a cell before placement? To Prison Directors: mChec/rpoint includes a request for assurance regarding SACRA, as below: SACRA I give assurance that all prisoners sharing a cell have a SACRA completed before placement in a shared cell. Can you identify the you use as Prison Directors to provide that assurance? Do you have any particular concerns about the current policy/process that you would like to be addressed? Can you identify any potential improvements that could be made to "to best ensure that staff fully understand and properly implement the process"? Department of Corrections SACRA Review 2017: Appendix Two Appendix Three: Chief Executive?s instructions on Shared Cells introduction 1 These instructions are issued under section 196(1)(b)(i) of the Corrections Act (2004) by the Chief Executive of the Department of Corrections and are particularto cell sharing and do not replace existing responsibilities or arrangements for prisoner management, except where something specific to the contrary is expressly mentioned. 2 The overall guiding principle is to provide a safe, secure, effective and humane environment for prisoners. 3 These instructions on cell sharing must be read together with regulation 66 of the Corrections Regulations 2005, amendments to which came into force on 1 January 2010. Commencement Date 4 These instructions come into effect on 1 December 2010. Conditions 5 The Prison Manager must ensure that all cells that are to be used to hold two or more prisoners are first assessed to determine their suitability for cell sharing. Such cells are to: . provide prisoners with adequate privacy (in particular when using toilets or showers). Modesty screens must be installed around the toilet if space allows. Cells without modesty screens should not be used as shared cells if other cells are practicably available . have working cell alarms/call buttons. Cell alarms and call buttons should be positioned so that prisoners can get to the alarm/call button without being stopped . be subject to adequate monitoring, having regard to the risks particular prisoners and cell conditions present. 6 Prison managers must also, so far as reasonably practicable: . use post?1999 shared cells or single occupancy cells in preference to pre?1999 cells, and 0 place prisoners who will get less out of cell time in post-1999 shared cells or single occupancy cells. 7 Prison managers must also prioritise maintenance of call buttons/alarms, modesty screensand ventilation for shared cells. Department of Corrections SACRA Review 2017: Appendix Three Prisoner placement I 8 The Prison Manager must ensure that, prior to being placed in a shared cell, all prisoners are assessed to determine their suitability for placement in a shared cell. This assessment shall be by way of the approved Shared Accommodation Cell Risk Assessment (SACRA). 9 Prisoners who are assessed as being unsuitable for placement in a shared cell must be housed in a single cell. 10 in addition: . prisoners classified as maximum security must be placed in a single cell . prisoners classi?ed as high security must not be placed with prisoners classified as minimum security - prisoners classified as low or low medium security can be placed with any other security classification, except maximum security prisoners - prisoners identified as ?at risk? of self harm must be accommodated in a single cell, unless it is determined that the prisoner would benefit from being accommodated in a shared cell. Health staff must be consulted before placing an ?at risk? prisoner in a shared cell . prisoners under 18 years of age must be placed in a single cell unless both prisoners are underthat age or when the exceptional grounds in regulation 180 of the Corrections Regulations apply . transgender prisoners are entitled to single cell accommodation if they choose, or to share a cell with other transgender prisoners if suitable to do so. 11 Prisoners? placement in shared cells will not affect their ability to access rehabilitation and reintegration programmes. Complaint and Review 12 Before prisoners are placed in a cell together, SACRA requires an i assessment of their compatibility. A complaint received by one or both prisoners about sharing a cell should be taken into account in assessing their compatibility. 13 Prisoners and staff must be able to raise concerns about particular instances of cell sharing, and access the internal complaints system in the prison in doing so, as well as having the opportunity to complain to external complaint hearers, such as the Inspectors and Ombudsmen. Staff must fairly and thoroughly consider prisoner concerns about cell sharing and, where justified, prisoner placements must be altered. Department of Corrections SACRA Review 2017: Appendix Three 14 As the assessment of risk and prisoner compatibility has the potential to change frequently, it is necessary to review prisoner placement in shared cells if there is an event that might affect either prisoner?s level of risk, or that triggers any other concerns. Such events include, but are not limited to the following situations: 0 a change of cellmate . deterioration in behaviour of one or both prisoners in the shared accommodation cell a deterioration in the relationship between the two prisoners required to share a cell . legitimate complaint from one prisoner regarding their cell mate . being the perpetrator of an assault . being the victim of an assault 0 intelligence obtained that increases the level of cell sharing risk. 15 in situations where an event has occurred or additional information becomes available that presents a particular risk with regard to sharing a cell or sharing a cell with a particular prisoner, placements in shared cells must be reviewed immediately. Department of Corrections SACRA Review 2017: Appendix Three Appendix Four: SHARED ACCOMMODATION CELL RISK ASSESSMENT - COMPATIBILITY GUIDELINES 'fho table summarises prisonercatogortes and attributes to consider before placing two prisoners in a shared call. Prisoner Category DataIts Prisoner Category Remand - Accused itemanded In custody for trial or iurther court appearances t'temend Accused Prisoners only (Co-accused prisoners should not share a cell) Remand-Convicted and remanded awaiting sentence Remand Convicted Awaiting Sentence Prisoners preferred (Sentenced prisoners may be considered as a second option) Sentenced Prisoners preferred Sentenced Convicted and sentenced to imprisonment (Remand Convicted Awaiting Sentenced Prisoners may be considered as a second option) Youth Prisoner ts aged 17 years or under Youth and Vulnerable Young Adu? Prisoners only Vulnerable Young Adult ml of to or year old determines Youth Unit placement Youth and Vulnerable Young Adult Prisoners only Young Adult UnderZD TBI oi it] or to year old determines mainstream placement Young Adult Under 20 and Adult Pdsoners only Adult 20 years or older Young Adult Under 20 and Adult Prisoners only Segregation aeann 60 Begrega?on tor 'Security. Good Order or Safety" Single Accommodation Celt only segregation Section 59 segregation tor'Protectlve Custody' 'Protecttva Custodr Prisoners only single Accommodation Cell only Segregation Section 60 Segregation tor the 'Purpose ofMedtcat Oversight" Trans people must be placed In a cell on their own and not double-bunker! with another prisoner. This may be overridden by the Prison Director" two trans people with the same gender Identitychoosa to be placed in Transgender a shared cell. The Prison Director must consider the suitability oi the Mo trans people to be placed to tho same cell using the SharedAccommodatlon Risk Assessment (SACRA). Other Factors Details Considerations Prisoner Request Prisoner requests a partlcutarperson to share a Are there any risks identi?ed that would provent these two prisoners from sharing a cell together? Prisoner Con?rmation Con?rm with the prisoners whether they know their potential cell mate Are there any risks Identi?ed that would prevent these two prisoners from sharing a celitogelher? Security classi?cation Con?rm Security Classi?cation of the prisoner Prisoners classified maximum security must be placed In a single cell. Prisoners classi?ed high security must not be placed with prisoners classi?ed as minimum security. Prisoners classi?ed as tow?ovr medium be placed with any other security classi?cation. except maximum security prisoners. Prisonerls deemed to be 'Al Rtsk? otseli harm The prisoner Is to be placed in a single cell. There maybe s?uallonswhare the bene?t from having a sulabla celi male. At Risk and requires staltobsorvation Consult with Health slat! before making this decision. is there a high risk of harm ltplaced with mainstream prisoners? Sethlender CheckSACRArepor-l -Prlsonerhas historicalorpresontsexual Doeathe prisoner need to be on 5?0"??an Section 59? offending against children. Can the prisoner be placed with anothersox ottenderlfsaia to do so? attending History Con?rm attending history (sexuatMotent only) How vulnerable Is the prisonarlrkety to be based on age. attending history. otience type. and experience In any form or cost Would they bene?t from a non-threatening cel mate as a ?buddy?? Would they gain more con?dence on their own? ist time prisoners may have dif?culty adjusting to prison life or How vulnerable Is the prisoner I-kety to be based on age. attending history. ottence type. and experience In any form at custody? Experience prisoner culture Would they bene?t from a non-threatening col mate as a 'buddy'? Would they gain more con?dence on their own? Check SACRA report . Con?rm relative age groups. Similar aged Age Group offenders may have similar ?mu" or ?le experience in common Is there rtskotone prisoner standing over or threaten ng the other prisoner because eta signi?cant age difference? How Is the alert relevant to sharing cell accommodation with others? IOMS Alerts other Risks check SACRA report and current prevention Information 9.9. Non ?sodium Alert 'Not to associate with PrisonerX' Gang Af?liation Check SACRA report - Evidence ofgang association from records, knowledge ofslali. CPIC and evidence such as gang related tattoos Least suitable for shared cell accommodation will rival gang members. more vulnerable prisoners. or sex otienders. Be wary at strengthening gang factions with yourcell sharing placement decision. Prisoner's physical characteristics The prisoner Is built. fruit or heavy eetr'muscular Is there a riskofone prisoner standing over or threatening the other prisoner because oto signi?cant ditterence to size or strength? Cultural or Religious Identity Prisoner clearly identi?es with a cultural or religious group that may give them support in a prison environment. Like with like whenever possible to encourage positive Interactions on the basis of common understandings. Especially useful to Identify a suitable cell mate when English Is a second language. \l'loience to Others Prisoner has been involved in incidents in prison Involving actual or threatened violrmco toward others. May present a to others. Must consider any available evidence or analysis that the a risk to other prisoners. Considered least suitable torsharlng cell accommodation with others. NcohotrDrug Abuse Check status - A prisoner's alcohol or dependency could pose a risk to a colt-male tithey continue to pursue Its use In prison. lea with like -Non IDU together. IDU together. Always consider it the prisoner Is likely to coerce or stand over their cell mato Into or using contraband? MenlalHeallh Prisoner has a current mental health need that causes concern. Prisoner has been remanded for a assessment. Undercurrentmanagemunt tn the Uni orplaced In a location to manage the mental health need. Vulnerable to being intimidated andtor stood over by others. Is there also a risk of escalation? May potentially be violent toward others. Consult with Health staff before making cell placement decision. Special Needs Prisoner has a physical or lntelecluai disability. Ongoing conditions only. Disablity may mean the prisoner Is vulnerable irom others. Depending on tho dlsebttitya groatarnoed for privacy. cell space may be required. or assistance from a helpful cell mate. Consult with Health stallbefere making this decision. Heath Needs Prisoner has signi?cant health risks to. Infectious diseases (such as Hepatlts or HIV). The prisoner may have to be accommodated separately or be more appropriately accommodated in a shared celL Rater to 6-1-1 Advice oi Prisoner Health Status fonn' provided by Health or consult with Health stair before mating cell placement decision. Employment Prisoner required to work In industries or otherwork related areas that require early unlock on a regular basis. The prisoner may have to be accommodated separately or be more appropriately accommodated with another prisoner taking lnto consideration their employment activity. Signi?cant Personal Event A signi?cant personal event ts brought to slalfaltenlton such as the death ota farnly member. a prisoner may bene?t from separation from others orhavtng a cell-main to support them In such a personal crisis. Explore these tho prtsonerwhen completing the POM ht.05 Prisoners at risk of salt harm (assessment) generated by such an event. Consider the risk of cell harm or suicide as the most signi?cant risk ?rst. it not at risk. determine ltsharlng a cell or not having a cell male will benern the prisoner as support through their personal crisis. Ask the prisoner open ended questions regarding the situation and their personal prersrenca. Department oiCorrectlons SACRA Review 2017: Appendix Four I.tJti.Ras.tJt SACRA compatibility guidelines Le st Updated: 25 Aug 2017 Appendix Five: Current SACRA Facilitator Guide Shared Accommodation Cell Risk Assessment (SACRA) Purpose The purpose of this topic is to train new staff in using the Shared Accommodation Cell Risk Assessment (SACRA). Objectives By the end of this topic staff will be able to: describe SACRA policy apply the SACRA compatibility guidelines tool to assess the risk of placing prisoners in a shared cell enter SACRA data on Resources Required for this module are: PowerPoint presentation IOMS Scenarios for eight prisoners Flipcharts and pens Access to POM Duration This topic takes approximately 45 minutes to deliver. Depadment of Corrections Sacra Review 2017: Appendix Five How to deliver this topic Activity 1 Split the class into groups of 4 or 5. Ask each group to answer the following question on fiipohart paper and report back to the class or run as a whiteboard session. What key risk factors do you consider when determining a prisoner's placement in a shared cell? Summarise the main points from each group. Lead discussion Emphasise that SACRA does not replace staffjudgement. SACRA is an assessment tool which is a collation of current practices that staff use to determine which prisoners should share a cell. The SACRA process provides evidence that supports your decision. Time Instructional component Resources! references Introduction Using the objectives give a brief overview of this topic. Explain that you will be using a PowerPoint presentation. 10 min Current Practice Flipchart Background Explain The Crown Law Office raised concerns about the lack of a formal process for assessing the suitability of prisoner placement in a shared cell. A recent judgement in the United Kingdom regarding the murder of a prisoner by his cell mate was a breach of Article 2 of the Human Rights Act, in that it failed to have in place an adequate risk assessment procedure. Reasons for Policy Ask What is the shared accommodation cell risk assessment? Talking points include SACRA does not replace staffjudgement or provide an actual risk score. SACRA identifies risk factors that need to be considered Department of Corrections Sacra Review 2017; Appendix Five Time Instructional component Resources] references when placing two prisoners in the same cell and recording them on IOMS. Supports staff's decisions providing evidence and protection for the decision you have made based on the information at the time. SACRA is completed using an automated process on IOMS, drop down boxes, search functions and comments field. Outlines a process to manage prisoners deemed not suitable to share a cell. Provides a record of cell sharing risks as a prisoner moves between wings or prisons Ask What is the risk of not documenting the reasons for placing two prisoners in the same cell? Although the number of shared cell incidents are relatively low. recording the reasons for placing prisoners in the same cell outlines that potential risks have been considered and reasons that supports staff?s decisions. Policy Presentation Take staff through the SACRA presentation. Show slide 1 Purpose Talking points The emphasis of the SACRA report is to reduce the level of risk (it does not eliminate the risk). Reduce the level of risk by considering key risk factors in a consistent way. Show slides 2 and 3 General Requirements Talking points The SACRA report is only generated if the prisoner is required to share a cell. The reason unit staff should complete the assessment is they will have a better understanding of prisoners they deal with on a daily basis. Therefore they will have a better knowledge of possible risks and mitigation. Show slide 4 Determining Prisoner Compatibility Talking points The Compatibility Guidelines is a tool developed as a result of feedback from focus groups around the country. it lists the key risks that staff identified should be considered. SAC RA PPT Department of Corrections Sacra Review 2017: Appendix Five Time instructional component Resources] references Show slide 5 Prisoners assessed as not suitable Talking points The PCO of the unit where the prisoner is residing must be informed of the decision within 72 hours to validate the decision. The review period must be no longer than three months, unless approval has been granted by the P00. The prisoner assessed as not suitable to 'double bunk' must be placed in a single accommodation cell. Show slide 6 Single cell unavailability Ask How often do you think this occurs? Talking points Feedback received from Prison Services indicates that this situation does not occur often. Mitigation strategies may include but not limited to? Transfer the prisoner to another unitwhere a single cell is available. Transfer the prisoner to another unit where a suitable cell mate can be located. In extenuating circumstances, transfer the prisoner to another prison to locate either a single cell or suitable cell mate. Show slide 7 Reviewing prisoner placement Talking points Prisoners are monitored on a daily basis as part of Active Management. Prisoner compatibility should be monitored as part of the daily Active Management process. A review of a prisoner's placement in a shared cell will also occur under the following circumstances. - A change of cell mate. Deterioration in behaviour of one or both prisoners Deterioration in the relationship of the two prisoners. Legitimate complaint from of the prisoners. Being the perpetrator or victim of an assault. Intelligence obtained that increases the level of risk. Show slide 8? Prisoner complaints Department of Corrections Sacra Review 2017: Appendix Five Resources! another transgender prisoner, or in a Single Accommodation Cell. However, if they choose, and it is safe to do so, they may be accommodated with a non?transgender prisoner. Question five False Question six True Question seven True Question eight Time Instructional component references Talking points ?ideally" complaints about the allocation of a double cell should be resolved before the placement occurs. Information should be given to prisoners about the procedure for objecting to a cell allocation or advising officers why they believe they are unsafe in a double cell. (Crown Law report) Show slide 9 Youth Prisoners Show slide 10 Transgender prisoners Show slide 11 Recording results Talking points Provides a level of protection. Process easy to follow on IOMS. Show slides 12 and 13 Quiz Answers to Quiz Question one False The SACRA report does not provide a risk score. Question two False The SACRA report identifies key risks to consider. However, there will be some things that must be followed e.g. legislative or departmental policy e.g. offender status or security classification. Question three True Question four False A transgender prisoner may be accommodated with POM [08.10 Department of Corrections Sacra Review 2017: Appendix Five Resources] Time Instructional component references True Question nine False Prisoners are assessed prior to being placed in a cell with another prisoner. Health Staff SACRA Policy document Health staff that are visited by a prisoner should consider the prisoners suitability for double bunking and notify custodial staff through Advice of Prisoner Health Status form. SACRA Report and Compatibility Guidelines POM [.08 Take learners through the report. Explain where the risk factors Shared for the report are retrieved from. Accommodatlo Cell Risk Assessment See next page. Department of Corrections Sacra Review 2017: Appendix Five Prisoner: (ey Risk Factors Joe BLOGGS IOMS information Shared Accommodation Cell Risk Assessment PRN: 8765786 Prisoner Compatibility Guidelines Offender Status information pro-populated from Must be placed like with like - Remand accused . Sentenced, including remand convicted Age if under 18 ?Youth Prisoner' will pre- Must be placed like with like populate . Youth, including vulnerable young adult (18 -19yrs old) ?1849 Young Adult pre-popuiat - Adult. Including young adult under 20 (not vulnerable) if 20 and over? 'Aduil' will pro-populate Note: Age should be considered when determining placement within each category Offence Type information pro-populated from Current offence type should be considered when determining placement Sexual and Violent Offending History information pre-popuiated from Only Violent and Sexual history Historical offence type should be considered when determining placement Aetive Alert information pro-populated from Active Alerts should be considered when determining placement Active Charges lnfonnation pro-populated from Active Charges should be considered when determining placement Gang information pro-populated from Gang Affiliation should be considered when determining placement is the any pre~reception information about the offender that gives you cause for concern? Information pro-populated from IOMS Yes/No and the comments from the NARA will pre-popuiate. Does this Information impact on the prisoner's ability to safely share a cell with another prisoner? is this your first time in p?son? information pro-populated from Yes/No and the comments from the NARA will pre-popuiate. A prisoner?s ?rst time In prison should be consideration when determining placement Have you ever seen a or for any problems? Information pro-populated from YeslNo and the comments from the NARA will pro-populate. Does this information Impact on the prisoner's ability to safely share a cell with another prisoner? Is there anything special about you that we need to know so that we may be able to help you? information pre-populated from IOMS Yes/No and the comments from the NARA will pre-popuiatei Does this information impact on the prisoner's ability to safely share a cell with another prisoner? Note: Consider if the prisoner is a smoker or a non-smoker. Department of Corrections Sacra Review 2017: Appendix Five Time Instructional component Resources] references Compatibility Guidelines Explain The Compatibility Guidelines summarises prisoner categories and attributes to consider before placing two prisoners in a shared cell. Consultation with field staff identified key risk factors currently considered when we place prisoners in a shared cell. The Compatibility Guidelines provides a trigger point to investigate further areas of risk, such as: Health. Smokers or non smokers. Physical characteristics. Take staff through the Prisoner Cell Sharing Matrix poster. Talking points: Where the guidelines say 'must' or 'only' this refers to either legislative or departmental policy, othenNise there is a level of discretion. Where you have a level of discretion, justify your decision in the comments field in IOMS. Using SACRA in IOMS Ask learners to locate the Using SACRA in IOMS resource within POM. Advise that while a copy is included in workbooks learners should always check POM first for most up to date resource. Refer learners to SACRA Guide in their workbooks. POM l.08.Res.02 Department of Corrections Sacra Review 2017: Appendix Five Time Instructional component Resources] references 10 min Scena?os Explain Split staff into groups of 4 or 5. Distribute the SACRA Scenario handout to each group. Task Assess and place eight prisoners into four cells. Use the SACRA report for each prisoner and Compatibility Guidelines to complete the SACRA Results to outline your decision based on information known to you at the time of assessment. Allow 10 minutes for each group to complete the activity. At the end of the exercise, go through the SACRA Results report. The prisoners SACRA reports are real examples but names have been changed. Several prisoners do share the same cell. They are as follows: Prisoner BLACK and SMITH share a cell. Both voluntary segregation and smokers Prisoner RONALD and DAWN share a cell. Both similar ages, offence and non smokers. Prisoner and TAMA share a cell. Both voluntary segregation and non smokers. Prisoner BAKER Should not be placed in a shared cell. He has stated he wished to share a cell with another transgender only. There are no single cells available, where does he go? What is his health concern? Further investigation revealed he was HIV positive. Handout SACRA Scenano 5 min Summary Revisit learning objectives describe SACRA policy apply the SACRA compatibility guidelines tool to assess the risk of placing prisoners in a shared cell Department of Corrections Sacra Review 2017: Appendix Five I'Appelndix Six: Letter to the Chief Custodial Officer from the National Commissioner DEPARTMENT 0F CORRECTIONS AHA PDUTAMA AOTEAFIOA 17 October 2017 Richard Symonds Chief Custodial Officer Dear Richard Re: Review of the Shared Accommodation Cell Risk Assessment (SACRA) process Thank you for carrying out the Operational Review of the Shared Accommodation Cell Risk Assessment (SACRA). i am pleased there Were no systemic issues relating to staff decision making for shared cell placement identified. it was also good to see staff completing SACRAs were confident using the current framework, that prisoners seemed confident a major incident would be addressed immediately by staff and that some prisoners prefer sharing a cell. Immediate actions The data presented on SACRA timeliness and completion was of concern. Upon receipt of the information we took immediate steps to address this. The Regional Commissioners were provided with data on Thursday 28 September and by Monday 2 October, all regions provided assurance that there were no known safety risks associated with cell sharing arrangements. On Wednesday 4 October all regions provided action plans to me. These plans detailed the corrective measures put in place at each site to ensure improved compliance with the SACRA policy. While the plans differed between sites, key themes were regular reviewing of SACRA completion and timeliness and enhancing staff capability in relation to SACRAs. Performance improvements There have since been significant performance improvements. Data from 12 October, demonstrates this with an increase to 83.81% of 210 SACRA completed on time. While there were still 29 instances of SACRA being completed late all of these were completed within one hour after electronic cell allocation. Much of the performance improvements Can be attributed to the action plans and staff having visibility of the data in COBRA. The dashboards in COBRA provide a reliable report for staff to readily identify any instances where SACRAs are net completed or completed late. Visibility of these cases enables remedial work to occur and provides learnings to contribute to continuous improvement. It is important to note that when exceptions are identified and rectified, the remedial work will not alter the results in COBRA. While the results have significantly improved, there remains room for continuous improvement. All sites continue to work through instances of SACRA being completed late or not being started in line with their action plans. NATIONAL OFFICE, WELLINGTON Mayfair House, 44-52 The Terrace, Wellington, 6011, Private 0140 Phone: +54 4 400 3000 Fax: +64 4 460 3263 3 .Sites have identified the following circumstances as contributing to SACRAs being completed late or not being started: . Allocating prisoners to cells electronically before completing a SACRA. The electronic cell allocation assists to ensure the site?s capacity will not be exceeded and therefore may be considered a priority task in the moment. After the electronic cell allocation, the SACRA is completed to ensure the prisoners are compatible for cell sharing. The SACRA still occurs before the prisoners are physically located in the cell together and there is the ability for the cell allocation to change if the SACRA does not support the pairing. . Completing the on paper' and then completing the electronic cell allocation before completing the In IOll/lS. This relates to the sequential processing errors identified in the report. . Two prisoners relocating to a new cell together (as an unbroken pairing) for reasons such as the original cell needing maintenance. It is unlikely staff would deem it necessary to complete a new SACRA and this would produce a result of a SACRA not being started. - Not electronically removing a departing prisoner from a call before electronically assigning a new prisoner. This would present as a SACRA not being completed but the two prisoners would not have been physically placed in the cell together. Work? IS ongoing to overcome the above and further improve results. lt' Is expected that Prison Directors are able to justify any discrepancies and that no prisoners are physically p'iaced' In a cell together Without a SACRA being completed. Recommendations and ongoing monitoring and assurance endorse the recommendations outlined in the review. Strengthening the alerts process, assessing an IOMS solution and reviewing staff training requirements will be beneficial. improvements in performance generated by the action plans will be monitored by the National Findings and Recommendations Oversight Group (NFROG) on my behalf and will be reported to the Corrections Services Leadership Team in addition NFROG will develop a consistent approach to second line of defence checks to be used as a tool by the Operational Performance teams. in the short to medium term the Senior Adviser to the National Commissioner will also monitor the SACRA results In COBRA weekly and alert the respective Regional Commissioner?s Senior Adviser to any concerning r_-esults identified. Any future compliance issues identified through these processes will be included in_ operational performance reporting to the Deputy Chief Executive. NFROG will monitor progress against all recommendations in the review on my behalf. Rachel Leota Acting Naticinal Commissioner