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

During this inspection we looked at 2 quality statements. Overall, staffing levels had improved significantly and were supporting safer and more effective care delivery. Incident management arrangements had strengthened since the previous inspection.

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

The incident reporting policy had been reviewed and updated, particularly in relation to self-harm incidents. The revised policy provided staff with clearer guidance regarding reporting requirements, escalation processes and incident management.

The service had several mechanisms to monitor incidents and identify emerging risks. Monthly performance data was reviewed to analyse trends and themes relating to patient safety incidents, self-harm, staffing levels and service delivery. Incidents were routinely discussed during daily handovers, prison safety intervention meetings and clinical governance forums to support organisational learning and continuous improvement, evidence of which we viewed.

Staff we spoke with demonstrated a good understanding of incident reporting procedures and were confident in using the Datix reporting system.

At the time of our inspection, 12 incidents remained open on the Datix system. Of these, only 3 were recorded as overdue, and were about to be finalised by the head of healthcare.

The judgement for Safe systems, pathways and transitions is based on the latest evidence we assessed for the Safe key question.

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

The judgement for Involving people to manage risks is based on the latest evidence we assessed for the Safe key question.

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

Since the previous inspection in the provider had made significant progress in addressing staffing shortfalls across the healthcare service.

The service had successfully recruited 11 nurses, 1 healthcare assistant and 1 administrative support worker. Staff told us that these additional resources had improved service delivery and increased the number of clinics available to patients. A small number of vacancies remained; however, mitigation measures, including the use of regular bank staff and overtime helped to maintain safe service delivery while recruitment processes continued. Staff rotas were now planned up to 6 weeks in advance allowing more time to identify any shortages and arrange cover.

Dedicated leadership arrangements had been implemented within the Enhanced Care Unit (ECU), supported by a named clinical lead and 24-hour nursing cover.

We reviewed staffing rotas covering 10 randomly selected dates between April and July 2026. These demonstrated that planned staffing levels were maintained on all but 2 occasions. Where staffing gaps occurred, clinical leads had provided cover to maintain service provision.

Managers reviewed staffing levels regularly and these were checked during daily handovers. Any staffing shortages affecting service delivery were formally recorded through the incident reporting system, evidence of which we viewed during our inspection.

Mental health nurses were no longer routinely required to undertake medicines administration duties, allowing them to focus on their role.

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.