HMP Chelmsford

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We assessed 2 quality statements for this key question. We found the provider did not have effective governance systems in place to identify, assess and address the full range of risks.

Records were not always accurate, complete and contemporaneous in respect of each service user.

Feedback from both healthcare staff and prison officers was consistently poor about healthcare staffing levels, and the impact this had on morale.

There were indications of a closed culture, with some staff feeling unable to speak up due to intimidation and fear of being treated unfairly. Concerns raised were not always responded to or addressed, and incidents were not always recorded.

However, the service was aware of some of its challenges and were making improvements. They were responsive to our inspection concerns.

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

The judgement for Shared direction and culture is based on the latest evidence we assessed for the Well-led key question.

The judgement for Capable, compassionate and inclusive leaders is based on the latest evidence we assessed for the Well-led key question.

We gathered feedback from staff through interviews, informal conversations across the site, staff questionnaires and anonymous contacts to our call centre. Feedback was positive between teams, and many described the other as valued parts of the service. Staff told us that they all helped each other when needed. All healthcare staff told us the patients were their focus and at the heart of what they did.

Pharmacy staff gave positive feedback. They said they felt encouraged to raise concerns and make suggestions for improvement.

However, feedback from both healthcare staff and prison officers was consistently poor about healthcare staffing levels and the impact this had on morale. Staff described the workforce as unstable, and morale across both the primary care and mental health teams was reported to be low.

We also found indications of a closed culture. Some staff told us they did not feel able to speak up because they feared being treated unfairly or facing negative consequences. Several staff members appeared uneasy speaking to inspectors about their experiences. Staff gave examples of concerns being raised but not always recorded, responded to or addressed, and we were told that some incidents were not consistently documented. This meant we could not be assured that all feedback was being listened to or acted on to support improvements in the quality and safety of the service.

The provider told us they were taking these concerns seriously and, in response, had agreed with the governor to establish structured feedback sessions for both staff and prisoners. These sessions would be held separately to create a psychologically safe environment and encourage open and honest discussion.

The judgement for Workforce equality, diversity and inclusion is based on the latest evidence we assessed for the Well-led key question.

We found that the service did not have effective governance systems in place to identify, assess and address the full range of risks. Although the provider’s quality improvement plan included some issues, several significant risks highlighted during our inspection were missed. These included concerns about medicine safety, emergency responsiveness, poor record keeping, weak oversight of backlogs, and administrative processes that were not operating safely or effectively.

The service carried out regular audits, including reception and secondary screening, long‑term conditions, NEWS2, emergency bags and use of force. However, there was limited evidence to demonstrate that these were being used effectively to improve patient safety or performance.

The provider told us that the prison regime made delivering healthcare challenging, including high levels of gang‑related activity, restricted movement and limited time out of cell. These factors affected attendance at appointments and made it difficult to provide routine or wing‑based care. Staff also reported issues with cleanliness, hygiene and available resources in wing‑based consultation rooms.

The provider told us that staffing remained one of their greatest challenges. Arranging shift cover had been difficult during December 2025 and January 2026, and inconsistent communication with the agency had led to differences between planned and actual staffing levels. Following the inspection, they introduced actions to stabilise staffing, including greater local control of rotas, using an additional agency, and continued recruitment of substantive staff to reduce reliance on agency provision.

Throughout our inspection, we found record keeping on the clinical system was poor. Entries were not always completed promptly or consistently, making it difficult to follow care pathways. We found examples where missing documentation led to gaps in treatment, follow‑up or deterioration not being recognised. This created a significant risk, particularly because the service relied heavily on agency staff who depended on accurate clinical information. Since our inspection, the provider told us they had introduced nationally recognised templates, commissioned an independent review of their clinical system, and expedited access to the system in the segregation unit.

Communication within the service needed improvement, and some staff felt the service was disjointed. Leaders told us they had recently introduced daily safety huddles to improve handovers and oversight of risks, including long‑term conditions, neurodiversity and mental health needs. They also planned to introduce weekly bulletins alongside existing team briefings and monthly meetings.

The provider also described plans to improve patient communication and access to information through the ‘launchpad’ system, so that patients could view healthcare information from their cells. NHS App access was due to be rolled out by the end of March 2026, supported initially by increased wing‑based nursing. Additional in‑cell wellbeing resources were being developed, including podcasts and digital mental health support.

The judgement for Partnerships and communities is based on the latest evidence we assessed for the Well-led key question.

The judgement for Learning, improvement and innovation is based on the latest evidence we assessed for the Well-led key question.