HMP Bullingdon

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• 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 1 quality statements under this key question. We found the provider had implemented satisfactory measures to address issues we had identified during our previous inspection. Governance systems and partnership working had improved.

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.

The judgement for Freedom to speak up is based on the latest evidence we assessed for the Well-led key question.

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

At our previous inspection, we identified inadequate partnership working to address long standing issues which had impacted on patient care.

The appointment of a new head of healthcare had had a positive impact. Local partnership relationships, which had previously been strained, had improved markedly, despite the head of healthcare only being in post for 4 months. She demonstrated a clear understanding of service risks and had begun to take action to strengthen governance arrangements.

Clear local operating procedures had been jointly developed by healthcare and prison leaders, setting out roles and responsibilities in relation to the management of medicines’ hatches. Officer support was now allocated to queues, procedures were displayed at hatches, and patients had been informed via internal communications about the need to bring their identification. Evidence of senior leader spot checks was provided, and healthcare staff reported a significant improvement in officer support. However, despite this progress, safety risks remained. We observed occasions where medicines continued to be dispensed without an officer present, and some crowding occurred at medicines hatches.

To address long standing concerns with patient transport, healthcare staff had worked effectively with prison colleagues in the appointment of a new provider. This had resulted in improved reliability and a marked reduction in non‑attended secondary care appointments by patients.

Cleanliness and infection prevention and control arrangements presented a mixed picture. Some environmental improvements were evident, including new flooring and redecorated communal areas on the inpatient unit. However, several areas across the prison’s healthcare rooms remained in poor condition and were visibly dirty. Audits and spot checks did not accurately reflect risks, and we observed cleanliness and maintenance issues that had not been identified through internal assurance processes. These issues highlighted that further partnership working and sustained leadership attention was still required.

Oversight of incident management had improved, and at the time of inspection there were no overdue incident investigations, except for deaths in custody, which were being investigated. Since September 2025, 516 incidents had been recorded, averaging 73 per month, compared with 40 to 50 per month at the previous inspection. This indicated improved reporting levels.

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.