HMP Bedford

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 4 quality statements for this key question.

We found the provider had made some progress in ensuring staff had an improved understanding of how to complete care plans and risk assessments, although they were not consistently well-completed, and patients did not always receive the required care and treatment to meet their needs promptly.

We found staffing levels were not always safe; the health care team were frequently short staffed, and staff frequently had to work hard across different teams to fill gaps in the rotas. Although a successful recruitment campaign had resulted in job offers, start dates were significantly impacted by the delays in prison security clearance and changes in skilled worker visas.

The provider had updated their policy on reporting of incidents to align with community providers which was appropriate, however, we continued to identify incidents which had not been reported in line with policy.

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

At the last assessment we found incidents of self-harm had not been reported or investigated in line with trust policy.

During this assessment we found the provider had revised their policy to align it with their community model and incidents of self-harm were reported accordingly.

The service had an internal process to report incidents, although staff had not consistently reported unsafe staffing levels using the provider’s internal reporting systems when they occurred. We found there were several incidents where staffing levels were not safe and these had not been reported in-line with policy, this meant that appropriate investigations and learning had not taken place to improve patient safety.

Mental Health:
During this assessment we found there was a clear referrals process for mental health services. Most patients had access to mental health treatment and support when they needed it, however, this system had not worked for some number of patients.

Review of mental health records found that not all patients had been triaged promptly. For example, staff identified one patient with mental health needs during the reception process, but it had taken 11 days to undertake an initial triage for this patient.

Inpatient unit:
There was a referrals process for staff to make referrals to other internal and external healthcare services when required. However, staff did not always make timely referrals.

Review of care records for patients on the inpatient unit found that referrals were not consistently made promptly to meet their social care and physical health care needs. For example, staff had not made a referral to social care services for several weeks for one patient who required social care support. This patient’s social care needs were evident at reception and on admission to the inpatient unit.

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

Staff did not consistently assess individual patient risk; assessments were not always completed promptly and interventions to mitigate risk were not always clear.

Mental Health:
At the last assessment we found some mental health risk assessments were generic, or risks, goals and interventions were not clear.

During this assessment we found there had been some improvement, but some records still lacked clarity and were difficult to follow. For example, the risk assessment for one service user included details about family members the patient was in contact with, under a risk heading, which was not explained. When risks were identified, it was not clear in the patient record whether there were specific triggers or how risks could be mitigated.

Inpatient unit:
At this assessment we found staff had not completed risk assessments for patients on the inpatient unit when risks had been identified. For example, 2 of the patients were at risk of falls and this was evident from their patient record, however, falls risk assessments had not been completed for either patient.

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

At this assessment we found there were insufficient staff within the healthcare team to ensure patients received safe and effective care to meet their individual needs.

The mental health team was fully staffed, however there were vacancies in primary care that meant staff frequently had to work hard across different teams to fill gaps in the rotas. The provider had made considerable effort in recruiting to vacant positions and most positions had been filled with start dates agreed. However, delays in prison security checks had impacted on some new staff taking up their post. This had been further impacted by changes in the government minimum salary threshold for skilled worker visas in April 2025. This meant that a group of 6 staff appointed had not been able to commence their role as planned.

Staff in the mental health team told us they were regularly required to assist in administration of medicines, and this impacted on the amount of time they spent with patients on their caseload. This was evident in our review of rotas. Rotas showed the primary care team were also frequently short staffed and that the inpatient unit, which had an allocation of one nurse 24 hours per day was regularly left without cover during the day. When this happened, the nurse holding the emergency alarm was responsible for providing care to patients on the unit, as well as responding to emergencies and treating other patients across the prison. When they were able to, the emergency nurse based themselves on the inpatient unit but this did not work well. We spent time on the inpatient unit during our assessment and found there was no nurse on the unit during that time. Patients and officers told us that patients frequently had to wait long periods of time to be seen by a nurse, including for daily routine care. The impact of the absence of a nurse on the unit was also observed in patient records. For example, it was documented that one patient had a long wait to see the nurse for basic care needs to be met. This impacted on the physical and psychological well-being of patients.

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

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