IMB Annual Reports

- The significant increase in self-harm incidents, prisoner-on-prisoner assaults, staff assaults, and use of force incidents is a major concern.
- Prisoners with severe mental health issues are inappropriately detained within the prison, often for extended periods in the Care and Separation Unit, due to a lack of specialist secure mental health places and slow transfer processes.
- Time out of cell remains limited, particularly for vulnerable prisoners housed on the induction wing, and attendance at education and purposeful activity is consistently below capacity, hampered by high prisoner churn.
- The high number of complaints regarding access to healthcare and the unresolved nature of these issues indicate systemic problems with healthcare provision and communication.
- The frequency of short recalls places immense pressure on prison resources and significantly disrupts resettlement efforts, leading to loss of accommodation and support for vulnerable prisoners.
- Persistent issues with property going missing during inter-prison transfers cause significant distress and are time-consuming to resolve.
- The incentives scheme lacks transparency and objectivity, leading to prisoner distrust, a concern repeated from the previous year.

- The pervasive issue of illicit substances and mobile phones, exacerbated by insufficient searches and the absence of in-cell telephony.
- The overwhelming impact of Temporary Presumptive Recategorisation Scheme (TPRS) and early release schemes on the prison's resettlement function, leading to a high churn of prisoners and difficulties in motivation and engagement.
- Inadequate staffing levels that do not reflect the current complex cohort of prisoners, leading to staff exhaustion and limiting security measures.
- Budget reductions negatively impacting education, vocational training, and the availability of activity places.
- Persistent issues with the aging estate, including prolonged lack of heating and hot water, roof damage, and recurring pest control problems.
- Challenges in resettlement planning, including delays in Release On Temporary Licence (ROTL) processing, insufficient pre-release accommodation arrangements, and minimal resettlement planning for many TPRS prisoners.

- Significant budget cuts to education and workshops are narrowing curriculum and reducing purposeful activity opportunities, questioning Bure's designation as a training prison.
- The shocking treatment of IPP prisoners, including exclusion from fixed term recalls, has not improved despite being raised last year.
- There is a lack of specialised units for dementia and geriatric healthcare for the aging population, especially given no 24/7 on-site medical facility.
- A digital solution for adjudications has not been funded, leading to archaic and cumbersome paper records.
- Prisoners' wages at Bure are lower than many prisons, despite similar canteen prices, a concern raised last year.
- Staff shortages are exacerbated by officers sent on ‘detached duties’ and frequent escorts/bed watches, impacting operational duties and key working.
- There is no national property scheme, and loss of property on transfer remains a significant issue.
- Installation of CCTV on wings is severely delayed despite funding being agreed.
- Frequent self-harm incidents using razor blades suggest a need to replace them with electric shavers.
- Late roll calls and clashes between education and other purposeful activities persist, negatively affecting regime and appointments.
- Heating in Residential Unit 7 remains inadequate, particularly for elderly and vulnerable prisoners, a repeated issue.
- Breakdowns in laundry machines and shortages of stock impact cleanliness and prisoner provision.
- Slow accommodation repairs result in cold and draughty cells, especially in preparation for winter.
- Extended periods in segregation have negative impacts on prisoners' mental health and reintegration.
- Lack of urgency in assessments can lead to inappropriate extended segregation.
- Many prisoners are unable to access their Prison Offender Managers (POMs), compromising procedural justice.
- The number of formal complaints remains high, reflecting last year's position, with no clear timescale for Comp1A appeals.
- Inadequate funding prevents the introduction of a digital property management system within the prison.
- There is a lack of accessible showers in Residential Unit 4 for elderly or disabled prisoners.
- The library is frequently closed or offers limited service due to staff shortages, preventing browsing and resource use.
- Small classrooms and scheduling conflicts limit education attendance and progression in core subjects.
- Lack of workshop space, compounded by a recent closure, leaves retired prisoners without purposeful activity and contributes to low full-time employment numbers.
- The OMU office environment is dismal, with poor natural light, impacting staff working conditions.
- Friday visit cancellations due to staff shortages and a shortage of space for the visits service.

- Overcrowding and cramped living conditions in double cells, exacerbated by ageing accommodation and delayed refurbishment.
- Persistent safety issues, including readily available drugs, an increase in deaths, serious self-harm incidents, assaults, and use of force.
- Significant underperformance in training and resettlement, leading to 30% prisoner inactivity and excessive time spent in cells.
- Underfunded healthcare, with staff shortages, reliance on agency staff, inadequate mental health therapy provision, and long dental waiting times.
- Poor food quality and portion sizes, resulting in high levels of waste and numerous prisoner complaints.
- Difficulties for prisoners in contacting overstretched Prison Offender Managers and inconsistent key worker engagement.
- Ongoing issues with prisoners' property, particularly during transfers between establishments.

- The constant movement of prisoners, late arrivals from court, and out-of-area intakes increase pressure on reception and challenge the safe location of vulnerable prisoners with gang affiliations.
- Sodexo's promised initiatives, including a specialist in-patient mental health unit, a fully operational crêche, and a new workshop, have not materialised.
- The kitchen is not fit for purpose given the increased population, leading to concerns about food quality and quantity.
- Education provision for prisoners in the Care and Separation Unit (CSU) has not resumed, and mentally unwell men continue to be held in the CSU due to insufficient secure bed availability.
- The lack of a permanent crêche in the visits hall severely affects prisoners’ ability to maintain family relationships, and a high proportion of prisoners are released with no accommodation.
- The statutory 28-day time limit for mental health transfers is not in effect, and the daily food allowance for prisoners is inadequate. The prison also faces issues with high Mandatory Drug Testing (MDT) levels, housing vulnerable prisoners on the induction unit, and chaplaincy vacancies.

- Inadequate independent oversight and lack of transparency, especially concerning Controlled Waiting Areas (CWAs) and internal audits.
- Continued mixed-sex detention at Larne House and the implementation of a blanket handcuff policy, raising safety and dignity concerns.
- Highly inconsistent and often insufficient healthcare provision across facilities, notably the removal of prescription medication and lack of external regulation for some services.
- Substandard and undignified accommodation, including lack of natural light, fresh air, showers, and proper sleeping arrangements, compounded by excessively long detention periods.
- A strikingly low number of formal complaints, suggesting significant barriers and an unwillingness to address detainee concerns effectively.
- Persistent delays in case progression, repairs, and a defensive response to IMB inquiries, indicating systemic inefficiency and a lack of focus on continuous improvement.

- Failure of accountability at all levels, with important regular meetings (EDI, healthcare/residential manager, use of force management) not taking place.
- Failing infrastructure, particularly persistently out-of-order lifts, impeding prisoner movement and access to services.
- A significant increase in deaths in custody (from 5 to 9), with one particularly concerning death from drug overdose highlighting deficiencies in reception screening and welfare checks.
- Serious concerns about the Care and Separation Unit (CSU), with many cells unusable due to damage, leading to prisoners serving cellular confinement on residential wings.
- Rising self-harm and assaults, indicating a volatile establishment, with use of force rates highest among comparator prisons.
- Inhumane cell sharing due to inadequate privacy screening and a lack of sufficient single cells.
- Significant disadvantages for wheelchair users due to insufficient adapted cells and lift failures, as well as delays in transfers.
- Ongoing shortages of essential kit (bedding, clothing, kettles), exacerbated by laundry issues.
- Increasing numbers of frail elderly prisoners 'bed-blocking' 24/7 healthcare units, coupled with a lack of appropriate alternative accommodation and delayed ageing prisoner strategy.
- Prolonged remand times and delays in transferring sentenced prisoners, hindering access to education, work, and sentence plan interventions.
- Stalled refurbishment work on three Victorian wings due to contractor administration, with no work undertaken for nine months, incurring significant public cost.
- Recruitment challenges, including the lack of face-to-face interviews for prison officers, impacting staff quality and retention.
- Underutilisation of education, employment, and soft skills opportunities, and the well-resourced new library.

- The pervasive issue of illicit drug use, indicated by high positive mandatory drug testing rates and inconsistent searching protocols for staff and visitors.
- Persistent problems with antiquated infrastructure, overcrowding, and vermin, leading to regular breakdowns and poor living conditions despite refurbishment efforts.
- Inconsistent regime delivery, with many prisoners, especially those unemployed, spending over 22 hours a day locked in their cells, failing to meet out-of-cell targets.
- Challenges in healthcare, including the use of unsuitable accommodation for unwell prisoners awaiting specialist beds, mental health teams struggling with referrals, and delays in transfers to secure hospitals.
- Poor engagement with purposeful activity and education, exacerbated by the cohorting strategy which limits choice and access to opportunities based on wing location.
- Significant concerns regarding staff conduct, evidenced by a marked increase in complaints about negative treatment and a largely unimplemented key worker scheme.
- Disproportionate application of force, segregation, and basic incentive scheme placement against black, Muslim, and younger prisoners, with reasons remaining unclear.
- Ongoing frustrations with in-cell phone service (long waits for repairs, high call costs) and persistent issues with lost or delayed prisoner property during transfers.

- There is still a lack of in-cell sanitation on B wing (99 prisoners) with no concrete, funded plan to resolve this.
- The average number of prisoners in segregation has increased, and prisoners with mental health issues are often held there prior to lengthy transfers.
- The daily regime for prisoners is still inconsistent due to variable staffing levels and additional demands, limiting key working sessions to only the most vulnerable prisoners.
- Healthcare issues, particularly access to physical healthcare, mental health support, and medication issues, remain the highest category of applications to the IMB.
- Approximately 20% of prisoners released from HMP Bristol do not have housing on their first night of release, and short-stay prisoners do not always get sufficient resettlement support.
- The Home Office’s proposed changes to the visa system are likely to adversely affect the recruitment and retention of new prison officers, impacting the prison's ability to deliver a full regime.
- There is no agreed funding or implementation date for Launchpad, a digital system that would improve prisoner communications and free up staff time.
- Lost and missing property within the prison has increased, typically after cell transfers, and remains the second highest issue raised with the IMB.
- Illicit drugs, notably psychoactive substances and cannabis, remain readily available in HMP Bristol, contributing to prisoners being under the influence, and the number of positive mandatory drug tests is higher than target.

- Problems in the delivery of healthcare services due to staff shortages, poor coordination, and 'in-fighting' among external NHS functions.
- Staffing issues resulting from significant deployment of PCOs to off-site duties and high turnover of new recruits.
- Negative impact of mandatory reconciliation roll-counts on the regime, leading to missed appointments and purposeful activities.
- Inconsistencies in the quality, quantity, and distribution of food.
- Delays in dealing with prisoner complaints, leading to a loss of confidence in the system.
- Mental health services under sustained pressure from complex caseloads, staff shortages, and delayed transfers to secure hospitals.
- Under-resourcing in the primary care team and shortage of experienced nursing staff.
- Consistent failure to dispense medication in a timely and efficient manner.
- Continued lack of a structured and coordinated service for supporting prisoners on discharge.
- Stress caused to women approaching release due to last-minute information about accommodation.

- Ingress of illicit substances continues to be an issue, leading to concerns about prisoner debt and self-harm risk.
- Inadequate ventilation in Beaufort wing persists, making conditions inhumane in hot weather, a concern raised previously.
- The prison lacks sufficient purposeful activity spaces, meaning not all eligible prisoners can attend work or education full-time.
- Mental health staffing levels remain inadequate to treat the increasing number of prisoners with ongoing mental health needs.
- Issues with external transport (Serco) cause late arrivals, delayed first-night health screenings, and problems with prisoner transfers.
- Social activities and video call slots are limited, particularly impacting young offenders and families residing far from the remote prison.

- The persistent problem of relocating prisoners with mental health issues to suitable treatment centres, with transfers exceeding the 28-day stipulated timeframe.
- The ongoing issue of prisoner property management, particularly during transfers between establishments, with little or no improvement despite a national policy.
- The 'new' heating system is still not up to standard and lacks flexible controls, leading to discomfort for prisoners and staff.
- The education contract is considered unfit for purpose, with concerns about lessons not being delivered, low prisoner engagement, and difficulties in holding the provider to account.
- The overall condition of Brinsford is outdated and in a poor state of repair, requiring significant investment to bring it to an acceptable standard.
- Activity places are limited and not 'meaningful', failing to adequately prepare prisoners for work and rehabilitation upon release.

- Continued volatility, high levels of violence, self-harm, and suicidal ideation, with a culture of disbelief and lack of empathy among some staff.
- Inadequate safeguards, including the Detention Gatekeeper's failure to prevent vulnerable individuals from being detained, and insufficient Rule 34/35 processes.
- Unacceptably long wait times for Rule 35 appointments and the tendency to manage vulnerability in detention rather than release, exacerbating harm.
- Unfair and inhumane practices, including detention without a time limit, widespread handcuffing during hospital visits, and systemic interpretation issues.
- Deteriorating physical conditions of Brook House and Tinsley House, marked by grimy facilities, poor ventilation, and damp.
- Excessively long lock-up times and a substantial increase in separation and segregation, often used inappropriately and restricting detainee access to support.

- A concerning 14% rise in violence incidents and 22% increase in weapons found.
- Too many vulnerable prisoners (VPs) cannot be accommodated on dedicated spurs, leading to them being held on general spurs and self-isolating.
- Insufficient care and monitoring for prisoners who self-isolate, with poor record-keeping by staff.
- A dramatic fall in key worker sessions and negative impact on daily regime due to high staff sick leave.
- Significant strain on the segregation unit due to multi-unlock CSC prisoners, limited spaces, and management of young adults.
- Seriously ill patients treated outside the in-patient unit (IPU) due to lack of available cells, and severe delays (80 days) for mental health transfers.
- Disturbing cases of medication mismanagement and a failure to provide adequate communication for foreign national prisoners.
- Years of under-investment leading to deterioration of prison infrastructure and ongoing issues with lost prisoner property during transfers.

- Chronic overcrowding and significant cell sharing, with 392 prisoners sharing cells designed for one person.
- Persistent staff shortages, high turnover, and inexperience impacting rehabilitation, key work delivery, and overall regime.
- High levels of violence and unsafety for both prisoners and staff, exacerbated by insufficient CCTV coverage and increased drone activity introducing contraband.
- Deteriorating healthcare provision, including long waiting times for appointments, medication delays, and significant staff shortages with reliance on agency staff.
- A large number of prisoners are released without confirmed accommodation, often leading to re-offending and recall.
- Low attendance rates in education classes and the inconsistent recording of language needs for foreign national prisoners.

- Overcrowding: The prison remains overcrowded with, in the majority of instances, two men sharing a small cell and toilet, which could be considered inhumane.
- Violence: HMP Bedford is still the third worst among reception prisons for prisoner-on-prisoner violence, and the second highest for assaults on staff.
- Illicit Items: All evidence indicates drugs and other illicit items are commonplace, with 36% of MDTs positive and over 100 unsecure windows facilitating drone incidents and throwovers.
- Healthcare Provision: The healthcare service is questioned as not fit for purpose due to ongoing failures in safe care, treatment delays, staff shortages, and poor record-keeping, as highlighted by a CQC warning notice and high prisoner complaints.
- Purposeful Activity & Education: Only around 40% of prisoners are engaged in purposeful activity, which is below average, and the limited education curriculum (basic English/maths) discourages further engagement.
- Staffing Stability: The Board is concerned that many officers on overseas work visas could be lost due to changes in rules, significantly impacting the regime and stability of the prison.
- Prisoner Property & Applications: An antiquated paper-based system for prisoner property causes significant frustration and missing items, especially during transfers, and the high number of prisoner complaints suggests issues are not dealt with at first contact.
- D-4 Wing Management: Prisoners on D-4 (PCoSOs) face disadvantages including limited access to education and the library, and the wing appears less well managed with a lack of application forms.
- Segregation Unit Design: The glass in the observation panels in the new Care and Segregation Unit (CSU) is breakable, resulting in small shards that can be used as items for self-harm or weapons, and a more appropriate, un-breakable material has not yet been found.

- Persistent staffing shortfalls and an inexperienced workforce place continuous pressure on the prison, affecting core functions and prisoner support.
- Significant building and infrastructure deficiencies, including unsuitable in-cell furniture, unreliable lifts, and the lack of a central laundry, are causing ongoing operational problems and repair costs.
- Gaps in healthcare provision, notably the absence of overnight services and frequent cancellations of external hospital appointments due to escort shortages, compromise prisoner health and well-being.
- Ongoing delays in transferring prisoners with severe mental health needs to appropriate secure facilities, often leading to them being held inappropriately in segregation.
- Underutilisation of purposeful activity spaces, with only 63% of workshop places allocated and education vacancies, hinders rehabilitation efforts.
- High positive mandatory drug test rates remain a concern, negatively impacting the prison regime with associated violence, self-harm, and debt.

- Inconsistent and poor quality responses to prisoner complaints and issues raised in adjudications, reflecting a lack of respect and empathy.
- Poor professional standards and behaviours among some middle and senior managers, including bad language, poor meeting attendance, and inconsistent application of rules, leading to diminished trust.
- Ongoing issues with medication distribution due to lack of operational staff availability, and concerns that social care needs are not promptly assessed.
- Challenges relating to the significant change in role for the men's prison to predominantly remand, requiring timely resourcing and a differentiated regime.
- Inadequate climate control within the prison, with heating failures in cold months and fan shortages in hot months.
- Insufficient focus on employment skills opportunities for men, and a need for more work on the wellbeing of older prisoners and open-air access for women.

- The cancellation of ROTL continues to hinder prisoner rehabilitation and resettlement.
- There is uncertainty regarding prison expansion, including rapid deployment cells (RDCs) and new kitchen facilities, and whether ancillary provisions will be proportionally increased.
- Proposed significant reductions in education budgets (35%) raise concerns about maintaining educational outcomes for prisoners.
- A plan is needed to accommodate the increasing age profile of the prisoner population, including physical adaptations and appropriate care packages.
- The opportunities offered by the Governance Review for joint working, training, and prisoner development across both sites need to be fully exploited.
- Further follow-up work is required to assess the effectiveness of the Warren Hill regime against the high prisoner recall rates (approximately 50%).
- Enhancing the use of IT in prison is necessary to better equip prisoners for release.

- Urgent need for a comprehensive national older prisoner related strategy.
- Inadequate social care, including end-of-life and dementia care, for people convicted of sexual offences.
- Pressure on probation services inside and outside prison, leading to concerns about prisoners being released without appropriate accommodation.
- Lack of progress on providing individual prisons with reoffending rates information, which was suggested last year.
- Category D prisoners being transferred to HMP Ashfield without prior adjudication or opportunity to put their case.
- Need for improvements to simplify and fair the new split work week and related pay structure.
- Low staff morale resulting from the impact of key work reporting, providing escort staff in hospital, and occasional redeployment to other Serco prisons.
- The continued closure of the charity shop due to building work and staff shortages.

- Timely access to specialist mental health facilities remains a concern for the Board.
- There continues to be little tangible progress in the situation of IPP prisoners.
- The length of time taken and the quality of work for repair and maintenance jobs across the establishment, including project delays.
- Problems with prisoners’ property not always arriving in its entirety on completion of a transfer.
- The Victorian infrastructure giving rise to problems surrounding increasing numbers of frail older people, particularly those with dementia, end of life care and disabled prisoners.
- A large amount of food waste and debris outside accommodation wings, attracting pigeons and vermin.

- Prisoners’ excess personal property continues to be lost or mislaid due to 'sending prisons' not enforcing volumetric property controls.
- It takes too long to transfer prisoners with mental health problems to secure mental health facilities, often resulting in prolonged stays in the CSU.
- An increasing number of prisoners held out of area, coupled with the prison's rural location, makes maintaining family ties difficult.
- A lack of 'enhanced' gate security equipment at HMP Stocken remains a concern, despite being one of the larger public-run prisons.
- There is an insufficient number of cells suitable for prisoners with disability or mobility issues, especially given the ageing prison population, with new wings lacking such provision.
- Certain prisoners held in the CSU on suspicion of illicit activities are not sufficiently briefed by the security department about the reasons for their investigation.
- Some members of the Senior Management Team appear not fully committed to the aims of the equality and diversity department.
- Recruiting and maintaining prisoner representatives is difficult due to constant prisoner movements.
- The healthcare unit experienced high staff turnover leading to long delays in responding to prisoner applications/complaints.
- Issues have been reported with the newly opened pharmacy, particularly concerning reliance on agency staff.
- The oldest wings of the prison are showing signs of age, requiring repairs and refurbishment.
- Time out of cells in the late afternoon/evening has been restricted due to increased drone activity, impacting the regime.

- High levels of prisoner-on-prisoner and staff assaults persist.
- Inadequate scrutiny and penalties for prisoners blocking cell observation panels.
- Persistent long delays in transferring prisoners with complex mental health needs to secure hospitals.
- Continued failure to maintain the prison's fabric, with unacceptable shower conditions and slow repair of cells.
- Inconsistent key working and a critical shortage of experienced custodial managers.
- Property system failures, including items lost during transfer and delays at RIDS.

- Detained people's main concerns continue to be related to the uncertainty of their futures.
- Night-time arrivals and departures, which are outside the IRC's control, remain a continuing concern for the Board.
- Accessibility to roofs for detainees is an ongoing issue, posing a safety risk.
- There is an imbalance of temperatures within the centre's buildings.
- Mechanical ventilation within the centre requires upgrading.
- The female accommodation and their access to general facilities are somewhat restricted and considered inadequate for detention purposes.

- Persistent staffing shortages severely impact regime delivery, prisoners' experiences, and officer-prisoner relationships.
- Poor living conditions persist due to lack of major refurbishment, continued deterioration of buildings, and overcrowding.
- Ease of illicit drugs entering the prison, via drones, leading to increased drug use, debt, and prisoners choosing to self-isolate.
- A notable increase in the use of force incidents, particularly unplanned, raises concern.
- Unacceptably long waiting times for prisoners with severe mental health problems to be transferred to secure mental health units.
- Significant shortage of purposeful activity for mainstream category C prisoners, compounded by denial of access to the library due to staff shortages.
- Inconsistent delivery of medication and unaddressed issues with healthcare staff not returning for missed medication.

- An increase in prisoners arriving who are not ready for or willing to accept the open prison regime, coupled with continued challenges of illicit items entering the prison.
- The majority of prisoners are still housed in poor-standard, 80-year-old prefabricated buildings, a concern repeatedly raised.
- Insufficient and variable quality of contacts between prisoners and their Initial Point of Contact (IPOC) officers, an issue noted in previous reports.
- Inadequate digital provision, including limited Wi-Fi, fewer computers, and a lack of digital training, alongside workshop closures and limited phone privacy.
- Delays for many prisoners in gaining Release on Temporary Licence (ROTL), despite the OMU's efforts.
- Changes to prisoner categorisation and inadequate community provision (probation, approved premises) are creating systemic challenges for rehabilitation and resettlement.

- Longstanding issue with legionella in the prison water system, posing health risks and impacting shower access, with insufficient capital funding for a permanent solution.
- Significant challenges for prisoners with sexual offence histories in securing post-release employment, compounded by national policy preventing them from Release on Temporary Licence (ROTL).
- Much of HMP Stafford's old infrastructure does not meet modern standards, requiring additional funding to better meet prisoner needs.
- The relocation of the Senior Support Group (SSG) facility for older prisoners resulted in a loss of outdoor space and natural light.
- Gaps in mental health and psychosocial substance misuse service leadership led to reduced oversight and extremely long waiting times (up to 34 weeks) for interventions.
- Inconsistent communication regarding CSU transfers and Rule 45 hearings hinders the IMB's oversight.

- The maintenance contract with Amey is viewed as expensive and ineffective, hampering necessary repairs such as TV signal updates, laundry facilities, and toilets.
- Significant problems with property during transfers, including bags failing to arrive with men and valuables not being sent.
- Increasing numbers of long-term residents are being transferred out of Buckley Hall against their will, disrupting family ties and progression.
- The policy prohibiting birthday parcels sent by family members is detrimental to men without sufficient funds to purchase items from the catalogue.
- There is an ongoing delay in introducing the promised 'handyman scheme'.
- Incidents of self-harm are high, with 81 reported in the final quarter of the reporting year.
- Accommodation and facilities are tired, with poor quality repairs, frequent shower outages, and an inconsistent television signal.
- Overcrowding is an issue, with cells being small for two people, leading to men being sent to CSU for refusing to share.
- Persistent hygiene concerns in the serveries, where food is often left uncovered overnight.
- Rats are a significant problem, exacerbated by rubbish bags left in unsecured cabinets outside wings.
- Cooking equipment on most landings is unhygienic and unsafe, and a dedicated wing kitchen proposal is stalled due to population pressures.
- The waste compactor has been out of use for much of 2025, leading to expensive and insufficient skip usage.

- Persistent gang culture, widespread illicit drug use (over 50% estimated) and associated debt, fear, and violence, including the manufacturing of bladed weapons.
- High levels of violence, including assaults on staff (107 in last 3 months) and prisoner-on-prisoner, with officers sometimes intimidated from reporting incidents or activating body worn video cameras.
- Chronic staff inexperience due to a large influx of new recruits, impacting fair treatment, staff-prisoner relationships, and leading to communication challenges.
- Inadequate regime provision, with insufficient time out of cell (7.25 hours per week reported) and frequent delays or cancellations of purposeful activity.
- Significant concerns regarding prisoner mental health, including insufficient in-reach staff, inappropriate use of CSRU for severe mental health cases, and extreme delays in transfers to secure units.
- Overcrowding pressures and inappropriate prisoner allocations, with Swaleside being used for purposes it is not equipped for, like resettlement, leading to further instability.
- Ineffective measures to combat contraband entry (drugs, phones, weapons) via drones and the main gate, with illicit items consistently ranked as a ‘serious risk’.
- Persistent issues with maintenance of kitchen equipment, delays in fitting new equipment, and the continued reliance on Swaleside’s kitchen to feed HMP Standford Hill, creating significant pressure.
- A backlog of adjudications, with a high number dismissed or unaddressed due to prisoners refusing to attend, undermining prison discipline.
- Lack of adequate support for prisoners upon release and persistent theft of stock from the DHL workshop.

- Staff absence and inexperience remain unacceptable, hindering regime delivery and care.
- Despite improvements, the prison is not safe, with violence levels still too high and basic operational errors noted.
- Living conditions are inhumane due to cell sharing, failing infrastructure, inadequate heating/hot water, and vermin/mould issues.
- The new healthcare unit has design faults and no residential capacity, leaving inadequate mental health units in use and causing long waiting times for clinics.
- Inadequate support for foreign national prisoners, who comprise nearly half the population, persists.
- Prisoners are frequently denied sufficient time out of cells, impacting access to exercise, showers, education, and other activities.
- Significant issues with lost or mislaid prisoner property continue to cause distress.

- Persistent issues with the quality and oversight of ACCT documentation and CSIPs, along with the absence of an effective Listener scheme.
- Significant and ongoing shortcomings in healthcare provision, including poor administration, long waiting times, medication issues, suboptimal staffing, and critical delays in mental health transfers to external facilities.
- Inadequate and inconsistent resettlement services, particularly probation and pre-release support for all prisoners, including remand, often leading to homelessness and a lack of employment on release.
- Challenges in maintaining fair and consistent treatment, exemplified by poor management of prisoner property and inconsistent application of the incentives policy.
- Late arrivals of court vans after lock-out times, negatively impacting prisoner and staff welfare.
- Lack of secure storage for visitor property and inconsistent visitor information, which remains unaddressed.

- Five serious incidents of violence against officers, as well as four committed by prisoners against other prisoners, one of which was an apparent homicide. Violence against staff increased in later months.
- The Board was concerned about food quality and quantity, portion sizes, hygiene in serveries and the poor state of the main kitchen.
- There remain some showers on each wing in very poor condition.
- Segregation staff found it difficult to deal humanely with some seriously mentally ill prisoners who attacked officers whenever their cell was opened.
- Keywork sessions improved in frequency, but the quality of discussions varied widely.
- Important functions such as visits administration and general applications processing suffered from staff absence.
- The administration of social and legal video visits was chaotic, leading to long waits and frequent short notice cancellations.
- 21% of health appointments were missed, with 9% (over 1000 appointments) due to officers not escorting prisoners.
- Staff shortages late in the reporting year reversed the trend of improved opening for Education and workshops.
- Vocational work continued to be low quality, with no replacement for previously lost contracts. Unemployment was almost double the target. Anticipated major cuts in the education budget will worsen the situation.
- Aging infrastructure and an inadequate property management system.
- Insufficient training to new officers on how to manage prisoner relationships.

- Persistent violence, self-harm, and the presence of illicit items, exacerbated by a lack of effective perimeter security.
- The dilapidated state of the prison's estate, particularly the segregation unit and heating systems, which are not fit for purpose.
- Inequities in access to purposeful activity, education, and healthcare for prisoners with disabilities and older prisoners, and the lack of essential rehabilitation programmes.
- The continued detention of foreign national men beyond their sentence expiry and delays in mental health transfers, leading to prolonged stays in segregation.
- Suboptimal healthcare provision, including inconsistent emergency equipment, long waiting times for appointments, and rejected mental health referrals.
- Ineffective key worker scheme and limited communication channels for prisoners, alongside concerns about the quality and meaningfulness of ACCT documents, especially for non-English speakers.

- The continued prevalence of illicit substances and a high rate of positive drug tests.
- An increase in self-harm incidents and the need for improvement in the ACCT process.
- Poor management of use of force incidents, posing risks to staff and prisoners.
- Persistent issues with prisoners sharing single cells and unresolved building design flaws, such as poor airflow.
- A high number of complaints about property loss, especially during transfers, linked to an inefficient paper-based national system.
- Challenges in healthcare, including inaccessible complaints boxes for some, a lack of electronic communication, and prisoners' lack of understanding regarding medication changes.
- Staffing issues affecting the education department and leading to long periods of unallocated prisoners.
- The absence of a resident psychologist impacting parole assessments.
- External factors influencing resettlement outcomes like employment and accommodation, and the failure to meet ROTL targets.
- The lack of a facility to provide photographic ID on release.
- National issues concerning an increasing number of recalled prisoners, faults in new prison design, and IMB member recruitment.

- Detained individuals are consistently denied access to their own medication across facilities.
- Most facilities lack full-time medical professionals, relying on emergency NHS services for healthcare needs, which the Board finds unsatisfactory.
- The safety and dignity of women are compromised by being housed in a corridor with male accommodation at Manchester RSTHF.
- Holyhead Port lacks a secure vehicle bay, leading to transfers being conducted in public view and a low rail near the dock posing a safety risk.
- East Midlands Airport's holding room is inadequate, lacking hot food, a television, and essential safety/security upgrades like CCTV, with detainees sometimes held in the Controlled Waiting Area.
- There is a concern regarding the slow rectification of structural and equipment deficiencies across all facilities, exemplified by cold and draughty conditions at Birmingham Airport.
- A consistent approach to control and restraint training needs rolling out to all staff for uniformity across the estate.

- First-night cells were often lacking basic equipment and welfare calls were not always given on arrival.
- Accurate completion of ACCT documents remains an issue, and the documentation is over-complicated.
- There was an insufficient number of Listeners in the prison for most of the year.
- The crumbling fabric of the prison and poor conditions, including vermin infestations and damp cells, remain a serious concern.
- Minimal levels of key work took place, with no proper system for allocation or monitoring.
- Pentonville remains a completely unsuitable environment for prisoners with mobility issues.
- The mosque remained out of use due to extensive flooring damage from an undetected leak.
- An increase in the availability and use of new psychoactive substances (NPS), often resulting in medical emergencies.
- Government-imposed measures to reduce prison overcrowding impacted the offender management unit’s ability to fulfil its remit, causing anxiety and frustration.

- The disruption to the prison population has resulted in the prison struggling to maintain its effectiveness as a vehicle for rehabilitation. It is essential that open prisons are given the stability to focus on rehabilitation, and this can only come with a more stable and appropriate prison population.
- Standford Hill’s initiative in establishing a prison shop is to be commended, but it could be improved by employing staff with the right level of experience or provide training in running retail businesses. If the management of the shop can be improved, the service should consider a bigger premises with a more ambitious remit in order to serve the prisoners better.
- Staffing levels at night are very low, raising concerns about whether the prison is adequately resourced to respond effectively to unexpected incidents.
- Technology to validate release on temporary licence (ROTL) has been suggested in previous reports - we believe this needs to be implemented to save significant staff costs.
- The provision of PIN phones has been discussed for a very long time. It needs to be implemented to support relationships and rehabilitation.
- While we appreciate that the prison has tried to obtain authorisation for non-internet mobile phones, this needs to be pursued. The current telephony provision is inadequate.

- The destabilising effects of accelerated prisoner churn, impacting safety, behaviour, healthcare, education, and resettlement.
- Significant delays in the refurbishment project to install in-cell sanitation, leaving over a third of prisoners without facilities.
- The widespread availability of drugs and illicit substances across the prison site.
- The persistent challenge of staff retention and the impact of new immigration visa rules on newer staff.
- The slow transfer process for mentally unwell prisoners, often resulting in prolonged unsuitable segregation.
- Insufficient recording of use of force incidents on camera.
- The continued prevalence of property-related complaints due to inadequate handling systems.
- A 'loitering culture' with many men not engaged in purposeful activity during core hours.

- The significant increase in prisoner receptions and churn has negatively impacted prison stability, staff workload, and resettlement opportunities.
- Persistent availability of illicit substances, contributing to violence and debt, with mandatory drug tests peaking at 44% positive.
- The poor condition of older wings (A and B) and plans to increase double cells raise significant concerns about decency and humane accommodation.
- Insufficient time out of cell, particularly for unemployed prisoners or those on a basic regime, remains a concern.
- Severely mentally ill individuals continue to be housed in prison due to a lack of suitable institutional places.
- Prisoners serving Imprisonment for Public Protection (IPP) sentences struggle to make progress through the system and access appropriate courses.
- Inconsistency in staff communication, regime application, and the fair application of the incentives scheme across different wings.
- Significant delays in receiving drug test results, hindering prosecutions and affecting prison security.
- Concerns about officer retention, training adequacy, and the profile of key worker sessions.

- Staffing levels are frequently under pressure, disrupting regime and impacting prisoner welfare, violence, and mental health.
- Inconsistent provision of activities and education, compounded by over-stretched staffing, high remand population, and budget cuts.
- A significant increase (28%) in illicit substance finds, linked to increased 'code blue' incidents, violence, and poor prisoner health.
- Late delivery of prisoners by SERCO contractors, causing staff to work late and impacting welfare.
- The total number of self-harm incidents (784) remains high and is the highest in its comparator group.
- Assaults on staff (148) and prisoner-on-prisoner assaults (273) remain high compared to other similar prisons.
- The use of force incidents (960) is 40% higher than the comparator group average.
- Accommodation is overcrowded and dilapidated, with most single cells housing two inmates, and significant building repair delays (e.g., CSU, control room).
- The Care and Separation Unit (CSU) capacity is frequently reduced due to cells being out of action, and it is inappropriately used for prisoners in acute mental health crisis.
- Healthcare complaints increased, and doctor visits to the CSU did not meet required frequencies.
- The high proportion of men on remand (over 70%) affects participation in purposeful activity and contributes to churn.
- Resettlement planning is under pressure from early release schemes and high caseloads for staff.

- Inadequate reception interviews for risk identification and lack of privacy at Swinderby RSTHF.
- Ongoing concerns regarding Home Office policy preventing detainees from taking their own medication for pre-existing conditions.
- Unsuitable physical conditions and routine use of handcuffing at some port and reporting centre STHFs (e.g., Leeds Bradford, Hull, Sheffield Vulcan House).
- Significant restrictions on the IMB's access to STHF records, compromising effective and independent monitoring.
- A serious breach of medical confidentiality and shortcomings in emergency healthcare response following an attempted suicide at Swinderby.
- The Home Office's consistent failure to respond promptly and adequately to IMB concerns and escalations.

- The ongoing challenge of re-sentencing for IPP prisoners in the open estate.
- The significant workload and pressure placed on prison departments by temporary early release schemes (SDS40).
- The failing system for transferring prisoner property between establishments, leading to increased complaints.
- The constant need for increased investment in capital projects and maintenance for the prison estate, including rusting modular units.
- Persistent issues with 'did not attends' (DNAs) for healthcare appointments, wasting resources.
- The Board's continued advocacy for single room accommodation for all prisoners to enhance privacy and dignity.

- The prison continued to struggle to deliver the improved outcomes planned for young adults in the last 12 months and in some areas has provided reduced outcomes.
- The prison is under resourced and fails to be recognised for the very specialist role it carries out with a high-risk population that presents with many issues.
- The Board has consistently been told by both staff and young adults that they consider the prison to be fundamentally unsafe.
- Many wing-based staff lack confidence, or are too scared, to direct and challenge young adults over poor behaviour, and to build meaningful relationships.
- Reduced availability of staff due to sickness, unauthorised absence, restricted duties, suspension, resulting in wing closures especially at weekends.
- Failures to search thoroughly for weapons resulted in increased injuries.
- Significant delays in timely production of OASYS reports for recently sentenced young adults.
- The paper-based applications (prisoners’ written representations) system is not effective and the promised review to make improvements was not delivered.
- Not enough purposeful activity places were available, and the curriculum lacked ambition and was impacted by staff absence and unfilled vacancies.
- Relationships between staff and young adults were too inconsistent, with key work sessions held infrequently, if at all, for most young adults, a reflection of the considerable inexperience among the staff group.
- The prison lacks enhanced gate security to prevent illicit substances from being smuggled into the prison.
- When will the prison be provided with kiosks and young adults with laptops to facilitate improved communications and ease the many unnecessary frustrations the Board observes young adults enduring every day?
- The HMPPS prison officer appointment process continues to result in some unsuitable appointments.
- What is the roadmap to end the practice of constant wing closures at weekends where young adults are held in patrol state for half of every weekend day?
- When can the Governor commit to introduce a fully operational key worker scheme?
- Can the Governor ensure the regime reset and current staff training model will address the imbalance between negative (>80%) and positive (<20%) entries on young adults computer records?

- The needs of complex individuals with multiple mental health issues are not adequately met in prison, and such prisoners take up a disproportionate amount of staff time.
- Continued detention and repeated recalls of IPP prisoners for relatively small breaches of licence conditions are considered unfair and inhumane.
- There are concerning safety trends, including a significant increase in self-harm incidents, assaults (particularly prisoner-on-prisoner), ACCTs opened, and use of force incidents.
- Drugs are reported to be available on one particular wing, posing a safety concern.
- Problems persist with poor communication between prisons regarding health information and missing property during transfers, causing delays in medication and other issues.
- The Board is concerned by the routine practice of using escort chains during intimate medical examinations or confidential consultations outside the prison, and by the number of prisoners declining breast screening.
- Prisoners lack adequate access to digital technology, hindering their preparation for life in a digital society, and perceived the Incentives Policy as unfair.

- The increased number of complex and mentally unwell prisoners compromises safety, leading to high self-harm rates and an increased number of deaths in custody.
- Long-standing maintenance and repair delays across the prison estate, particularly in the houses, compromise decency standards and pose fire safety risks.
- Lack of consistent staff supervision on the houses and inadequate staffing for escorts impacts safety, prisoner access to support, and regime delivery.
- Significant delays in transferring severely unwell prisoners to appropriate mental health placements and insecure medication storage remain critical issues.
- The incentives scheme is not robust or fair, and opportunities for prisoner voice and effective monitoring of equality and diversity have declined.
- Insufficient activity spaces and significant pressure on finding accommodation for prisoners on release, exacerbated by short-term recall prisoners.

- The continued removal of highly vulnerable individuals, including those with severe mental health conditions or at risk of self-harm, often without proper authorisation.
- The consistently long periods of in-vehicle confinement for returnees, often through the night, deemed unfair and inhumane by the Board.
- Unreliable processes for identifying interpretation needs and the inconsistent provision and explanation of professional interpreting support.
- An increase in the use of restraint on returnees, coupled with concerns about the accuracy and completeness of use of force documentation.
- The potential breach of medical confidentiality due to the mass handover of returnees' prescribed medication and medical notes to receiving authorities.
- Inadequate and unsanitary toilet facilities on coaches, including lack of privacy, and the demeaning use of disposable urine bags in vans.