HMP Chelmsford

On this page

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

We assessed 5 quality statements for this key question. We found risks to patients were not always assessed, monitored or managed effectively.

• Incidents and complaints were not always consistently recorded, reviewed or monitored.
• There was no formal or reliable safety‑netting system in place to make sure tasks, scanning and referrals were reviewed and acted on.
• Medicines management was mostly positive. However, some records about patients’ medicines were incomplete, and medicines and equipment were not always monitored to ensure their safety and effectiveness.
• Improvements were underway towards the response to patient emergencies, including a review of emergency bags and changes to communication practices.
• Patients with diagnosed and undiagnosed neurodiversity needs received tailored support.
• Safe staffing levels were not consistently maintained because shortages were not accurately recorded. Staffing levels in both primary care and mental health were described by staff as unstable and, at times, unsafe.
• Staff recruitment checks were mostly completed in accordance with regulation but there were some gaps. There was a programme of learning and development for all staff.

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

There were processes to identify, record and act on incidents. However, staff did not consistently follow these processes. Whilst themes and trends of incidents, safety events, complaints and patient feedback were analysed and discussed at senior meetings, management did not have a complete picture of all the relevant data.

The systems for reporting and managing incidents were not working well. Incidents were not always recorded, reviewed, or monitored. This meant we were not assured that appropriate actions were always taken to reduce risks or prevent incidents from happening again.

We found incidents were not always recorded, especially those involving emergency codes or staff shortages. This was confirmed through our review of incident data and staff feedback. Healthcare and mental health staff said they felt encouraged to report incidents, but they did not always have enough time to do so.

Staff told us they usually received feedback on incidents they personally reported and received a debrief. However, they told us they felt learning from incidents was not shared consistently across teams, and staff said they were not always told when actions had been completed.

Pharmacy staff gave positive feedback. They said they felt encouraged by their manager to report incidents, that concerns were taken seriously, and that learning was shared in team briefings.

Prior to our inspection, concerns were raised about communication with patients. We reviewed 5 patient complaints and found that key information had not been recorded or managed consistently. Details were missing, including who investigated the complaint, the actions taken, the response provided, whether the patient was satisfied with the outcome, and whether any learning or improvement actions had been completed or shared. We also found that the date of the complaint was not included on the complaints spreadsheet, and the date each complaint was received was not always recorded accurately.

The patient engagement lead had recently taken responsibility for the complaints process and described several improvements underway. They were attending a range of patient forums to gather suggestions, identify any reasonable adjustments needed and respond to questions. They were also updating information for patients to understand how to make a complaint, and they were developing ways for patients to give compliments and positive feedback about their care. The patient engagement lead was continuing to ensure that themes and trends from complaints and feedback were fed into governance meetings to support learning and improvement.

We spoke with a range of staff during our assessment, including clinical and non-clinical staff across all services, who told us they worked with each other and patients to ensure safe systems, pathways and transitions.

Prior to our inspection, concerns had been raised about staffing levels and how this affected the management of important information, including the processing of correspondence, test results and referrals. At the time of our inspection, we found that test results and prescription requests were being reviewed and actioned promptly. However, staff told us they did not always have enough time to complete all administrative tasks, and that backlogs of information sometimes built up as a result.

We found systems for identifying, monitoring and responding to delays in administrative processes were not fully developed. At the time of our inspection, there were 1,961 open tasks on the system, with the oldest dating back to January 2023. Staff told us there was no consistent method for categorising tasks or highlighting those that were urgent. For example, 935 tasks were labelled as “miscellaneous,” which made it difficult to understand what they related to or whether they required immediate action.

Referrals to specialist services that we saw were documented and contained the required information. We saw that all urgent referrals had been sent. However, staff reported they were not confident that all non-urgent referrals had been sent or that all necessary follow‑up actions had been completed. We found 32 referral‑related tasks, most of which asked staff to chase appointments or results. The oldest of these was from November 2025. Referrals were tracked on spreadsheets but there were gaps in recording, particularly whether patients had attended their appointment or required follow up.

Hospital discharge summaries were not managed effectively. Due to staff shortages within the admin team, discharge summaries were not always obtained and when they had been received this was not always documented accurately. There was also a number of documents waiting to be scanned on to the system.

Because of these gaps, we were not assured that there was a formal or reliable safety‑netting system in place to make sure tasks, scanning and referrals were reviewed and acted on. This created a risk that people might not receive the follow‑up care and treatment they needed.

Healthcare staff and the prison had systems in place to support people when they were released or transferred. These arrangements were working well, despite challenges in maintaining continuity of care for patients with no fixed address and for those who needed support from community mental health teams or required ongoing medicines. Patients were seen by healthcare staff before they left, and local data showed that 87% of people leaving the prison had a supply of their medicines. In addition, 97% had their medicines with them when transferred to another establishment, although these figures were not reflected in national reporting.

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

Prior to our inspection, concerns were raised about the service’s capacity and capability to respond to emergencies.

We had mixed feedback from healthcare, mental health and prison staff about the response to emergencies. Some staff told us that clinical emergency response staff had the time, competency and confidence to respond. However, most staff told us there were not always enough staff to respond safely, and some staff were not up to date with the required training, which was supported by the training records we reviewed. The provider was receptive to these findings and has since arranged training for all staff who had not previously completed it.

There had been a recent incident where staffing levels fell below the minimum safe level for primary care, which prompted a review of the service’s business continuity plan. Staff gave examples of good practice that had resulted from this event, which we shared with the provider. We were updated that additional learning actions were being taken forward to improve communication, including the escalation processes, governance of the emergency radio, and role clarity.

Following an incident involving a patient, there had been a review of the emergency bags including medicines and equipment. They had also replaced some outdated equipment. All emergency bags were regularly checked, and there had been a lunchtime learning session to upskill staff on the contents and to improve visual recognition of items. We checked 2 emergency bags and found them to be tidy, labelled, and stored in a way that would aid staff to quickly find items. However, we found some items that were past their expiry date or not stored correctly. The provider told us they would take immediate action to replace the items and review their compliance checks.

During our inspection, staff described a positive initiative to identify people’s needs and provide holistic support for their health and wellbeing. A neurodiversity practitioner had recently been introduced who had been upskilled in their clinical role. They were working closely with the newly appointed Early Days in Custody (EDIC) manager to ensure that all people entering the prison, including those with diagnosed and undiagnosed neurodiversity, had their needs identified and addressed.
All new prisoners received a neurodiversity screening at reception, which was shared with the neurodiversity practitioner. They were then offered support tailored to their needs, which could include weekly one‑to‑one sessions. They also received a personalised ‘passport’ describing their communication preferences, triggers, support needs and guidance for staff on how best to help them. Copies were shared with prison staff to promote consistent support within a dedicated neurodiversity wing, but also across the whole prison.
The neurodiversity practitioner contributed to daily handover meetings and attended the weekly neurodiversity working group, where issues related to healthcare, education and wider support were discussed. Staff shared examples of positive impact, including individual case stories and results from a survey completed by those on the practitioner’s caseload. Feedback showed that their needs were being recognised and met more effectively.

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

Prior to our inspection, we received information of concern about staffing, including a lack of staff, untrained or unsupported staff, and occasions where staff were asked to work outside of their competency.

We reviewed recruitment records for 5 members of staff and found most of the required checks had been carried out. However, in 2 cases they could not provide sufficient information about why the staff members had left their previous jobs, where they had worked with children or vulnerable adults before. This meant we could not be assured the service had checked that these individuals were suitable for their roles.

We also found that staff vaccination records had not been fully checked in line with current UK Health Security Agency (UKHSA) guidance. For 3 staff members, recommended vaccinations were either incomplete or not confirmed. These included tetanus, polio, diphtheria and measles, mumps and rubella (MMR).

Using staff questionnaires and interviews, we received feedback from a wide range of staff across all teams. We also spoke with prison staff during our visit. The majority told us they felt staffing levels in both primary care and mental health were unstable and, at times, unsafe. Some staff described an unmanageable workload, being asked to work long hours, or undertake tasks outside their competency, and some reported that colleagues had left because they did not feel able to provide safe care and treatment. However, staff knew that leaders were trying to recruit permanent staff to bring stability and were filling any gaps with bank or agency staff.

Information we reviewed found staffing shortages were not being recorded accurately. As a result, the provider could not demonstrate that safe staffing levels were consistently maintained. Leaders told us that primary care should have a minimum of 3 registered nurses (plus one reception‑competent nurse) and that a GP was on site every weekday. However, when we reviewed information for December 2025 and January 2026, along with what staff told us, we saw 4 examples of inconsistencies. Changes to nurse cover and cancellations were not always reflected on the rota or logged as an incident. GP availability records were also inconsistent as the GP clinics recorded on the clinical system did not align with the provider’s data. Where GPs were not available, the GP clinic still appeared on the system even though no GP was present.

There was a programme of learning and development for all staff, and this included a range of mandatory training modules. We saw evidence that service leads had completed learning needs analysis for their team, which was part of the provider quality improvement plan. We also saw that training for agency staff was on the risk register.

Training completion was monitored by service leads and senior managers. Although some staff were overdue for their training, the provider told us these sessions were booked in. As well as online and external training, there were opportunities for staff in-house, such as ‘lunch and learn’ sessions. For example, bespoke training was being developed for immediate life support and scenario training for emergency response. Leaders also told us they were aware of specific gaps in skills and competencies, for example, that no permanent staff were catheter‑trained and there was reliance on agency staff for this task. The head of training was reviewing this to strengthen skills within the permanent workforce.

We were given mixed feedback from staff about training. Some staff told us they were given enough time to attend training, were encouraged to take up opportunities, and progress in their career. However, some staff in the primary care and mental health team said it was difficult to complete training because they were not given additional time, or they had to complete online training at home. They also told us that they had fewer opportunities offered to them in recent months.

We were told about an improved range of support offered to staff, including restorative supervision, on-site wellbeing support, reflective practice sessions, remote professional nurse advocacy, and senior leadership support. Staff also had access to occupational health and the employee assistance programme. However, we were told that formal supervision sessions, including clinical supervision, were not consistently taking place.

The judgement for Infection prevention and control is based on the latest evidence we assessed for the Safe key question.

Medicines were supplied by an on‑site pharmacy, and medicines were administered twice a day, at 8am and 4pm, across 7 wings. The pharmacy team worked closely with the wider healthcare team and supported repeat prescribing, particularly when psychiatrist cover was not available. However, gaps in pharmacy technician posts meant that agency staff often had to support medicine administration.

Almost all people arriving at the prison (99%) received a medicines reconciliation on entry, helping to ensure their usual medicines were safely continued. At the time of our inspection, 28% of people were able to keep their medicines in possession. There was also an out‑of‑hours system to access critical medicines, such as antibiotics, although we found one example where a person waited five days for a critical epilepsy medicine. People could obtain treatments for minor conditions, such as creams, through the canteen list.

During our inspection, we observed poor monitoring of the refrigerators used to store medicines. Temperatures in January 2026 had risen as high as 19.6°C, above the safe range, and there were multiple gaps in the temperature records. There was no evidence that any action had been taken in response to these unsafe readings. Following our visit, the provider ordered data loggers to strengthen oversight.

Staff feedback about the pharmacy team was consistently positive. Pharmacy staff told us they enjoyed being part of the team and felt well supported. Staff from both the primary care and mental health teams also told us the pharmacy team was helpful, responsive and a valuable part of the wider service.

We saw staff administering medicines in a calm and respectful manner. People were treated with dignity, and officers supported confidential conversations when needed. However, paper ID cards were still sometimes being used to identify people during medicine administration, despite this having previously been raised as poor practice by NHS England. Following our inspection, they updated that almost all prisoners now had ID cards printed. The pharmacy team continued to escalate remaining IDs, which were delayed due to prison‑related operational issues.

Electronic records did not always contain accurate information about people's medicines. Records also did not always show whether people had actually received their medicines, including critical medicines. In addition, not all actions required after people returned from hospital were being completed. Records relating to controlled drugs were being completed correctly.
The provider acted quickly in response to our concerns and told us they were implementing corrective actions to prevent any further lapses in monitoring or record keeping.

The pharmacy lead produced a monthly report for medicines management meetings, where incidents, learning and improvement actions were reviewed. A twice‑daily safety huddle allowed staff to raise urgent concerns about medicines. A range of audits were taking place, including checks on people prescribed anticoagulants, audits of controlled drugs, and ensuring people who needed them had emergency steroid cards. A recent audit comparing antipsychotic prescribing across 2 prisons supported by the provider did not identify concerns about overprescribing or documentation.

Pharmacists were also completing around 3 to 4 structured medication reviews each month, which were high quality and contained the information we would expect to see. Access to prescribing stationery was controlled, and prescriptions were stored securely. Staff carried out around 15 to 20 in‑cell medicines checks each month and responded promptly when issues were found.