HMP Bullingdon

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We assessed 1 quality statements under this key question. We found the provider had implemented effective measures to address most issues we had identified during our previous inspection. The assessment of patients’ needs and care planning had improved, although food and fluid intake needed to be monitored effectively.

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

At our previous inspection, use of Exceptional Safety Assessments (ESAs) had presented a risk to patient safety due to their high usage and inconsistent follow‑up with comprehensive reception screening. At this inspection, the provider had made considerable progress. A revised ESA policy had been implemented, clearly defining appropriate use and timescales. This had been effectively communicated, and staff demonstrated a good understanding of the revised process.

There had been a substantial reduction in overall ESA usage, indicating they were now being used appropriately as a last resort when prisoners arrived late in the evening. An audit of ESA use from November 2025 showed only 8 instances where a full reception screen had not been completed for a patient. Safety‑netting arrangements were effective, with outstanding reception screens identified and followed up at the new arrivals meeting the following day.

The management of healthcare applications for appointments had improved. Previously, there had been no effective clinical triage system and patients sometimes experienced long waits for responses. At the time of this inspection, responsibility for applications had been allocated to the unscheduled care team, with a named clinician allocated daily to triage applications according to clinical need and ensuring onward referral to the most appropriate clinician. Response times had also improved significantly. For example, in December 2025, some patients had waited over a week for a reply; by March 2026, responses were typically provided within 24 to 48 hours. Sampling we undertook over the preceding 3 months confirmed that all patient applications had been responded to within 5 days.

The inpatient unit (IPU) showed improvement in several areas. Admission processes had been strengthened to ensure only patients with a clear clinical need were admitted. This had resulted in a reduction in IPU capacity of approximately 50%, improving the ability to provide focused clinical care. Multidisciplinary team pre-admission meetings were documented in all but one case we reviewed.

Clinical assessments had improved. Records we reviewed demonstrated consistent completion of patients’ falls risk assessments, pressure risk, nutritional risk, and Rockwood scores where appropriate. Care planning processes were more robust, with evidence of weekly review to ensure that any changes in patient need were identified. Patients were now actively involved in completing their care plans and were able to show their plans to us. The proportion of patients with long‑term conditions who had an active care plan had increased from 23% in December 2025 to 69% in March 2026. However, some plans lacked sufficient detail to ensure staff delivered consistent and personalised care to patients.

Nutrition and hydration monitoring remained an area requiring improvement. Although food and fluid charts were completed more frequently, they were not used effectively to support clinical decision‑making. Fluid totals were not consistently calculated, minimum intake targets were not documented, and there was limited evidence of clinical review. As a result, these records did not provide effective oversight of patients’ nutritional and hydration needs.

Previously, there had been a lack of meaningful therapeutic activities. At the time this inspection, therapeutic activities were taking place from Monday to Friday, supported by a timetable displayed for patients. The Patient Liaison Team had clear responsibility for delivering these activities, and we observed sessions taking place. Patients spoke positively about the activities, reporting that they helped to break up long, boring days. However, access to formal accredited therapeutic interventions remained limited and had not yet been fully implemented.

Medicines management practices had also improved. At the previous inspection, unsafe practices were observed, including a failure to confirm patient identity and inaccurate controlled drugs records. During this inspection, we observed medicines administration at 4 hatches across the prison. Staff consistently asked patients to confirm their identity and date of birth, and controlled drug records were completed contemporaneously, reducing the risk of medicines errors.

Emergency preparedness was stronger. Oversight of medical emergency equipment checks had improved, with only 1 missed check recorded in March 2026 compared to 13 missed checks in December 2025. Emergency bags we inspected were fully stocked and contents were within date for safe use.

The judgement for Delivering evidence-based care and treatment is based on the latest evidence we assessed for the Effective key question.

The judgement for How staff, teams and services work together is based on the latest evidence we assessed for the Effective key question.

The judgement for Supporting people to live healthier lives is based on the latest evidence we assessed for the Effective key question.

The judgement for Monitoring and improving outcomes is based on the latest evidence we assessed for the Effective key question.

The judgement for Consent to care and treatment is based on the latest evidence we assessed for the Effective key question.