IMB Annual Reports

- There were 19 deaths in custody, including 5 believed to be drug-related.
- Food complaints were constant, covering both quality and quantity, with kitchen facilities designed for a smaller population.
- The number of keyworkers remained lower than required, leading to prisoners complaining about lack of contact.
- Persistent issues with inter-prison transfers meant prisoners' property was often not transferred with them.
- Mental health provision had issues, particularly with ADHD assessments, and there were significant delays in accessing secure mental health beds.
- Waiting times for GP appointments and emergency ambulances were frequently excessive, compounded by a shortage of nursing staff.
- Education was restricted at times due to regime constraints, and there was a decline in the quality of education and purposeful activities in the YOI early in the year.
- The uncertainty of release dates for IPP prisoners caused significant anxiety and negatively impacted their mental health and progression.
- Violence levels in the YOI continued to fluctuate, with an increase observed during April-June 2024.

- Men who are out of therapy cannot move on to another prison due to overcrowding, impacting the effective running of the therapeutic community.
- There are very few opportunities at Grendon for men to build on their experiences once they are Out of Therapy (OOT) and remain too long.
- Ongoing issues with building infrastructure, poor sanitation arrangements in non-refurbished wings, continued rat infestation, and overheating.

- The UK government continues to under-invest in rehabilitation services for open prisons, specifically in offender management and educational/vocational services.
- Persistent issues with outside probation and other agencies delay men’s access to Release on Temporary Licence (ROTL), exacerbated by new early release schemes.
- Fluctuations in demand due to early release schemes like SDS40 overwhelm on-site services, particularly mental health.
- The poor state of Springhill’s infrastructure (leaking buildings, unreliable fire alarms, power outages, failing sanitation, rats) seriously impacts the ability to deliver a safe and enabling environment.
- Staffing problems in core education subjects and the Offender Management Unit (OMU) hinder men's progression and access to resettlement support.
- Activities designed to support men's progression towards sustainable employment remain disjointed, leading to underemployment in low-value on-camp work.

- The ongoing loss and delay of prisoners' property during transfers and within the prison, exacerbated by issues with handling parcels.
- The continued poor service and untimely completion of maintenance works by Gov Facility Services Ltd (GFSL).
- The significant rise in healthcare applications, requiring investigation into underlying reasons.
- The incomplete replacement of external netting, leaving the prison vulnerable to "throwovers" and contraband, impacting prisoner safety and wellbeing.
- The persistent influx of large quantities of drugs and other contraband, contributing to an increase in violent incidents and drug debt.
- Concerns regarding prison overcrowding, which complicates prisoner transfers and contributes to increased violence and unrest.
- The IMB is concerned that one of the constant watch cells is located in the CSU.

- Acutely mentally unwell prisoners held in segregation for long periods awaiting hospital transfer.
- Overwhelming presence of illicit items, particularly due to drone incursions, and high positive drug test rates.
- Significant regime restrictions and long hours in cell due to cancelled evening association.
- Poor accommodation conditions (dirty cells, missing items, un-refurbished showers) and issues with food hygiene and portion control.
- Understaffing in Offender Management impacting sentence progression and access to offender behaviour courses.
- Persistent accessibility issues for prisoners with mobility needs due to broken lifts and lack of ramps, compounded by the needs of an ageing population.
- High self-harm incidents, particularly among IPP and recall prisoners, and concerns about cell bell response times.

- Incidents of self-harm have continued to increase and are more prevalent than in other LTHSE prisons, linked to drug availability and lack of purposeful activity leading to violence.
- Outdated and failing security systems, coupled with frequent drone deliveries of illicit items (drugs, weapons, phones), compromise safety and security.
- Four wings lack in-cell sanitation, requiring the undignified 'slopping out' process, which falls below modern standards of decency.
- The prison’s infrastructure and fabric continue to deteriorate, with ineffective maintenance provided by Amey plc, and critical facilities like the kitchen remaining unsuitable.
- Inefficient management of prisoners’ property remains a major source of frustration and anger, leading to mistrust and self-harm.
- Healthcare in-patient facilities are unsuitable for supporting prisoners in poor physical health or providing therapeutic support, contributing to long waiting times for transfers and GP appointments.

- Extremely high self-harm rates, significantly increasing year-on-year.
- The ongoing complexity and impact of running two parallel regimes.
- Poor fabric and maintenance of accommodation blocks, particularly A, B, C, and D wings, with delays to repairs and issues with contractor performance.
- Ongoing issues with prisoner property, reflected in a high number of applications.
- Lack of dental services for nearly a year, leading to transport needs and long waiting times.
- Insufficient purposeful activity and education spaces for the prison's population size, impacting prisoner progression and time out of cell.
- Delays in resettlement planning for high-risk men and foreign national prisoners.
- Some areas of the prison estate, particularly heating and water systems, are beyond repair and unsuitable for prisoners and staff.

- The impact of the Female Offender Strategy Delivery Plan on short sentences and the relatively low number of prisoners at Askham Grange.
- How the Prison Service promotes the benefits of open conditions, particularly given Askham Grange remains below capacity and receives prisoners with insufficient time to benefit from opportunities.
- Lack of services to support prisoners who have been subject to sexual and domestic violence, despite Governor's requests.
- Healthcare complaints process is not evident, transparent, or encouraged, with prisoners feeling discouraged from complaining.
- Ongoing problems with phone lines, impacting family contact.
- Lack of a managing chaplain.
- Traka medication distribution lockers being out of action for the entire reporting year.
- Uncertainty of central funding for the reading specialist post and lack of funding for the prisoner health champion role.
- Prisoners' reluctance to submit complaints due to fear of return to closed conditions.
- Dissatisfaction with how a small number of staff interact with prisoners.

- The increasingly complex nature of the prison population has led to a rise in self-harm, violence, and bullying, making some women feel unsafe.
- The prison faces staffing resource concerns, with a minimal number of officers available impacting the basic regime and staff morale.
- The poor and dilapidated conditions of Richmond and Plymouth houses, dating back to WWII, remain a long-standing and unresolved issue for over 20 years.
- The use of the Care and Support Unit (CSU) to manage women with acute mental illness awaiting hospital transfer is a disturbing and unacceptable systemic problem.
- Property delays and losses, particularly during transfers, continue to be a significant and distressing problem for women, often remaining unresolved.
- The regime is more restrictive compared to pre-pandemic, with inadequate opportunities for fresh air and meaningful exercise for women.
- The education budget has seen no increase for over 10 years, leading to a real-terms reduction in resources.
- The increasing number of women transferred with short sentences or close to release impedes rehabilitative work and preparation for release.
- Ongoing problems with medication management, including administration processes, control of prescription trading, and dispensary design.

- Cookham Wood was an unstable and unsettling place for boys, with makeshift weapons commonplace and a pervasive fear of violence.
- Boys were frequently locked in their rooms for over 20 hours a day, consistently failing to meet the minimum standard of two hours out of cell, which the Board deemed inhumane.
- The constantly changing regimes and broken promises about activities and association time shattered trust, leading to significant frustration, anxiety, and low self-esteem among the boys.
- Insufficient officer numbers frequently meant education and purposeful activity were irregular and inconsistent, limiting opportunities for rehabilitation.
- The decision to close the YOI, and the lack of timely, concrete information, caused extreme uncertainty and anxiety for boys being relocated far from home, and severely damaged staff morale.
- Overall, there was an appalling lack of clarity of leadership and impactful project management from YCS and HMPPS regarding the closure and the future of highly trained staff and budgets.

- The centre is less safe than previous years, with increasing fights, assaults on staff, frequent lockdowns, and a rise in throwovers, illicit drugs, vapes, and phones.
- People who are mentally unfit for detention are still assessed and approved for detention, exacerbated by Operation Safeguard bringing more Foreign National Offenders (FNOs) who contribute to increased violence.
- Failings of the Detention Engagement Team (DET) to engage effectively contribute to frustration and powerlessness, potentially leading to self-harm incidents.
- The dilapidated infrastructure, frequent loss of services (power, gas, water, communications), and lack of significant investment severely test the fairness and humanity of treatment.
- Concerns about the variety, quantity, and quality of food on offer, impacting physical and mental well-being, as well as safety and security.
- The Care and Separation Unit (CSU) is being misused, including for facilitating removal directions days in advance of cancelled flights, housing individuals who refuse to share rooms, and for mentally ill detained people, contrary to Detention Centre Rules.
- Complaints regarding contracted services are not believed to be properly investigated, leading to a lack of trust in the system, with 77% of complaints unsubstantiated.
- Staff shortages and lack of escorts result in cancelled hospital appointments and worse health outcomes for detainees.
- Too many detained people are held for unacceptably long periods without the prospect of imminent removal, including those held for over 200 days.
- Delays in finding suitable accommodation for those granted bail, particularly for time-served foreign national offenders (TSFNOs), due to inconsistent communication between Home Office, Probation, and local authorities.
- Significant increase in throwovers (44 in 2023 vs zero in 2022) containing drugs and contraband, indicating a breach in security.
- Lack of progress on crucial investment in infrastructure, especially heating and ventilation systems, despite previous recommendations and a delayed new contract.
- Rule 35 reports are not responded to within the mandated two working days, causing Adults at Risk to remain detained when they should be released.
- Prolonged detention of mentally ill individuals in the CSU, contrary to rules, exacerbates anxiety and poor mental health, with no appropriate alternative mental health pathway.

- Significant rise in self-harm and high levels of prisoner-on-prisoner and staff assaults.
- Pervasive issue of illicit items entering the prison, including by drone, creating risks.
- Breakdown of the prisoner complaints process for much of the year, leading to frustration.
- Poor physical state and decency levels of older wings, with prolonged maintenance delays.
- Suspension of education and purposeful activity for three months due to staff shortages.
- High caseloads for prison offender managers, impacting prisoner progression.

- Significant increases in self-harm (34%), assaults (52%), and use of force (76%), indicating a decline in safety.
- Persistent overcrowding, with 90% of cells double-occupied, and unsatisfactory internal fabric, including damp, mould, and stalled refurbishment of A Wing.
- Deterioration in prisoners' feeling of safety, with 80% reporting feeling safe (down from 92%), alongside a 50.5% increase in drug finds and concerns about Spice and homemade drugs.
- Major issues in healthcare provision, including 14% of new arrivals missing first-night assessments, poor secondary screening, high "did not attend" rates, and a lack of cooperation between healthcare and operational teams.
- Inconsistent regime delivery with no improvement in time out of cell, poor attendance in education, and lack of motivation among remand prisoners for activities.
- Ongoing concerns about the quality and completion of ACCT documents (78% with omissions) and the prison being designated a cluster death site multiple times.

- Prisoners with complex and severe mental health needs remain too long at HMP Foston Hall due to delayed transfers to secure hospitals.
- A significant rise in remand, short-sentence, and recalled prisoners has led to an increase in drugs and illicit items, causing debt, bullying, and violence.
- The accommodation in the CSU and D wing remains inadequate, lacking funding for improvements.
- Without a body scanner at reception, staff are hampered from detecting concealed drugs, compromising safety.
- The rise in prisoner-on-prisoner violence is a significant concern.
- Problems persist with the prisoner application system, with responses often late or not received.
- Prisoners experience considerable difficulties and lengthy delays in accessing their property.
- Lack of shelter for prisoners queuing at the medication dispensing hatch in all weathers.
- Missed internal healthcare appointments remain significantly high.
- No social care 'buddies' for prisoners with care needs.

- The disadvantage faced by ex-PCoSO prisoners in gaining employment upon release due to reluctance from some businesses.
- Growing difficulties in securing timely and suitable accommodation for prisoners on release, risking homelessness and reoffending.
- The need for improved support services for an increasing number of very frail elderly prisoners with complex physical, mental, and social care needs.
- Concerns around prisoners’ unwillingness or reported reluctance to raise legitimate complaints or approach the IMB for support, fearing adverse consequences.
- Ongoing issues with the structural integrity of accommodation blocks and delays in completing the Fire Safety Improvement Plan.
- Concerns about the quality, quantity, and calorific value of meals.
- Prisoners arriving on transfer without prescribed medication due to travel distance.
- Mounting concerns from prisoners about changes to individual risk levels affecting progression, ROTL access, and release arrangements.

- Forest Bank continues to operate at capacity, raising questions about future expansion plans and support.
- The model for reception prisons, which are under significant pressure, requires review and evaluation.
- Staff and prisoner relationships, particularly the delivery and effectiveness of key worker sessions, need attention.
- Frequent missed medication dispensing times are impacting prisoners’ health.
- Illicit items remain an operational and safety challenge, requiring further investment and support.
- The management of prisoners with complex needs, especially regarding timely mental health transfers, continues to be a challenge.
- Cleanliness and maintenance issues on accommodation blocks, including out-of-use water coolers and lack of air conditioning, are persistent concerns.
- Rates of violence and use of force have increased significantly.

- Deeply concerning levels of self-harm, with Eastwood Park accounting for 38% of all prolific incidents in the women’s estate.
- 1039 use of force incidents, double the number from the previous year, with a small number of troubled prisoners being a key factor.
- Long delays for transfers to mental health units and inadequate provision for women with multifaceted social care needs.
- Under-used activity workshops that are not operating as originally intended.
- The significant adverse pressure on the regime and staff due to the concentration of individuals who prolifically self-harm in a single prison.
- Unfinalised proposals for replacing residential unit 7, which remains unoccupied due to fire safety concerns.
- Prisoners experiencing lengthy journeys to court due to the delayed operationalisation of a video conferencing centre.
- The impact of staff compassion burnout, injuries, and attacks on staff morale and goodwill.
- The running of the prison is negatively impacted by low staffing levels and a high number of inexperienced staff.
- Gaps in provision for programmes addressing offending behaviour.

- Staff are unable to effectively help prisoners with personal problems, and the ability to respond to loneliness has seen a catastrophic drop.
- Cell cleanliness and adequate equipping remain an unacceptable issue, with over half of respondents reporting unclean cells on arrival.
- The easy availability of drugs and hooch significantly compromises prisoner safety and rehabilitation efforts.
- Most prisoners (80%) feel they are not being helped by staff for life after release, and many struggle with literacy without adequate support.
- The complaints system is perceived as unfair by 79% of prisoners, and both Prisoner Forums and regime communications are largely considered ineffective.

- Incidents of residents climbing on to the roof remain an occurrence, despite previous recommendations for preventative measures.
- Detainees frequently experience late-night arrivals from Edinburgh airport, sometimes being returned the next morning due to lack of suitable overnight accommodation, raising concerns about night movements.
- One resident was able to escape from Dungavel during the year.
- The IMB itself faced significant difficulties in recruiting and retaining members, affecting its ability to fully monitor the centre.

- Three deaths in custody occurred during the reporting year, one apparently self-inflicted.
- There is an increasing number of prisoners with complex issues, many from outside the local area, which combined with national prison population pressure, has changed the demographics and can cause conflict.
- Long waiting times for healthcare appointments and cancellations are a significant issue for prisoners.
- Prisoners with serious mental health issues face lengthy waits for transfer to secure mental health units, leading to deterioration and violent behaviour.
- Property lost during transfers between establishments remains a major, repeated concern, despite computerisation improvements.
- Tight staffing levels have resulted in regimes being cut back, restricting time out of cell and activities.

- The continued prevalence of illicit substances and items entering the prison, exacerbated by a lack of external CCTV and gate searches.
- Insufficient provision of meaningful and purposeful activity, soft skills opportunities, and the absence of a Release on Temporary Licence (ROTL) facility.
- National delays in transferring prisoners with acute mental health needs to secure beds, resulting in extended stays in the Care and Separation Unit.
- Challenges in communication and collaboration with Home Office Immigration Enforcement (HOIE), causing anxiety for prisoners regarding their immigration status and release.
- A shortage of officers trained to quality assure Use of Force incidents, leading to delays in their proper scrutiny.
- The ongoing need for improved translation services for foreign national prisoners to understand official documentation.

- The inadequate phone provision continues to be an issue, impacting communication between prisoners and their families.
- The building infrastructure across Ford is failing, with a constant cycle of electrical issues, unacceptable internal drain conditions, and broken hot water systems, which poses a health and safety risk.
- The delayed prison expansion project is now not anticipated to be completed until 2029, following two main contractors going into administration.
- Budget for critical rehabilitation activities, specifically the Chichester College School of Construction, has been cut by 50% for the 2025 financial year.
- Delays in responses from Community Offender Managers (COMs) within the Probation Service are a major source of frustration for prisoners and staff, impacting ROTL and release planning.
- The Board reiterates that Imprisonment for Public Protection (IPP) sentences are inhumane and should be removed from existing prisoners.
- The low rates of pay in Engineering and Land Based Activities are a source of discontent for prisoners.
- The lack of purpose-designed rooms for prisoners with disabilities and the still unconnected disability alarm system in some pods are concerning.

- The general level and severity of violence, including fights and assaults, remain a significant concern.
- Educational provision is wholly inadequate due to restricted regime, violence, 'keep-aparts', and contractual issues.
- The inhumane accommodation of young people, legally children, far from family due to YOI Cookham Wood's closure, is a serious issue.
- Time out of room continues to be poor, especially at weekends, falling below pre-pandemic levels.
- Staffing levels in social care are low, impacting workload and support for vulnerable young adults.
- Monitoring of Rule 49 reviews by the IMB is hindered by infrequent submission of paperwork.
- The number of young people self-isolating has increased due to fear of others' behaviour and getting into trouble.

- Population pressures affecting reception and induction processes.
- Overcrowding and double occupancy of single cells.
- Extended waits for mental health transfers to secure hospitals.
- Difficulties with resettlement for out-of-area prisoners, leading to releases as 'no fixed abode'.
- Lack of adequate probation and community support for released prisoners.
- Cell bells not being answered quickly enough.
- Insufficient support and progression for IPP prisoners.

- The key worker scheme is barely functioning, with a compliance rate of just 11.5% for sessions allocated.
- The healthcare building is in a deplorable state, urgently needing temporary and long-term new accommodation.
- The kitchen roof is in a very poor state, with rainwater leaking through, causing extensive mould and peeling paint.
- The absence of an end-of-life care facility is a concern, especially given the elderly population and associated burden of bed-watches on staff.
- Need to expedite the introduction of a sex offence programme at The Verne, as many prisoners are released without completing one.
- The Offender Management Unit remains understaffed, leading to significant backlogs in OASys assessments and reviews.
- The more moderate regime and free association have led to increased bullying, coercive behaviour, and grooming of vulnerable prisoners.

- The prison is deemed 'less safe' than previous years due to a significant increase in prisoner-on-prisoner and prisoner-on-staff assaults.
- Serious concerns regarding delays in mental health transfers to secure hospitals for prisoners in urgent need of treatment.
- Ongoing staffing issues, including a reduction in experienced officers, use of detached duty, and unfulfilled key worker sessions impacting prisoner support.
- Urgent need for improvement in the physical security and aging infrastructure of the prison, which also impacts humane living standards and access to full regimes for those with mobility issues.
- Persistent issues with purposeful activity, with too many prisoners not engaged in education or work opportunities, compounded by limited higher-level and IT-specific education.
- Lack of progress in addressing repeated concerns, such as the astroturf pitch and timely property delivery.

- The prison's inability to appropriately manage prisoner transfers, receiving men with complex needs and insufficient sentence time for resettlement, exacerbated by population pressures.
- Unacceptable living conditions, including overcrowding (men sharing single cells), erratic decency checks, and chronic shortages of bedding, clothing, and furniture.
- Inconsistent and poor regime, especially on B wing, leading to prolonged time in cells and lack of purposeful activity for men awaiting induction.
- Pervasive availability of illicit items such as drugs, phones, and improvised weapons, contributing to self-harm, violence, and debt-related self-isolation.
- Inadequate education, skills, and work training provision, with significant induction backlogs and unmet learning needs in English and maths, contributing to boredom.
- Poor performance of subcontracted services (e.g., maintenance, vermin control, washing machines, cell bells, CCTV) affecting safety, decency, and regime.

- Levels of availability of illicit substances in the prison, reflected in high positive drug tests.
- Inconsistent wearing of body worn video cameras by prison officers for use of force incidents.
- Impact of outdated buildings and critical infrastructure breakdowns (cell bells, lifts) on fair treatment and safety.
- Prisoners with complex mental health issues remaining in the CSU due to lack of space in the healthcare unit.
- Unacceptable number of routine healthcare appointments and therapeutic sessions cancelled due to lack of prison officer availability.
- Long waiting times for assessment and transfer to external secure mental health facilities.
- Inconsistent and limited time out of cell for prisoners, with many spending 22 or more hours locked in cells.
- Marked increase in complaints about lost property, despite new policy framework.

- High staff absence significantly impacts regime delivery and time out of room for children and adults.
- Persistent violence, including prisoner-on-prisoner assaults and a worrying increase in staff assaults on Feltham B.
- The poor state of the built environment, including leaking roofs, damp, and mould, remains unaddressed despite previous reports.
- Insufficient purposeful activity, education, and vocational training provision, particularly for the older age group on Feltham B.
- Significant impact of non-associations ("keep-aparts") and gang-related issues on safety, regime, and opportunities for young people.
- Rise in contraband finds, including drugs and mobile phones, with obvious smell of cannabis on units.
- Closure of the Enhanced Support Unit (ESU) on Feltham A, depriving the prison of an important resource for complex needs.
- Lack of key worker sessions limits support and guidance for prisoners, impacting staff-prisoner relations.
- Issues with food provision, including inconsistent servery cleanliness, lack of PPE, and substantial amounts of food going missing.

- The process of transferring prisoners with mental health issues to secure units is too slow.
- Higher levels of funding are required to meet the complex and severe mental health needs of the women.
- The prison is increasingly being used inappropriately as a place of safety for women with severe mental health conditions.
- Prison is not an appropriate environment for women with severe mental health issues, with assessments and transfers to secure mental health establishments not prompt enough.
- There was a significant 61% increase in healthcare-related applications to the IMB, particularly concerning prescribing issues.
- The use of the vacant 'Larch' plot, previously identified as a concern, remains undecided.
- The shared Governor arrangements and clustering with HMP Askham Grange negatively impact New Hall prisoners' access to Release on Temporary Licence (ROTL).

- The disruptive effects of the HMP Dartmoor closure, including changes to the estate, redistribution of work roles, and pressure on activities and resettlement, have created a very challenging period.
- The persistent backlog in repairs to roofing, heating systems, and work-related equipment continues to adversely affect decency and purposeful activity.
- Missing property, especially on transfer, remains a significant and unresolved issue, causing distress and undermining trust.
- The long-term segregation of a prisoner on a 'dirty protest' highlights the lack of alternative solutions for managing challenging behaviour.
- Excessive waiting times for opticians and psychologists, particularly for VP group sessions (38 weeks), indicate gaps in healthcare provision.
- The absence of a national strategy for an expanding ageing prisoner population means local initiatives are insufficient to adequately meet needs, leading to unacceptable social care provision.
- Prisoners serving IPP sentences experience hopelessness, frustration, and poor mental health due to difficulties in progression and the lack of a resentencing exercise.
- Purposeful activity is undermined by instructor shortages and ageing, prone-to-failure infrastructure, preventing the 75% participation target from being met.

- Significant increases in self-harm (63%), violence (57%), and use of force (68%) incidents.
- Persistent overcrowding and unacceptable living conditions, including prisoners eating in shared cells with integral toilets, and issues with heating, hot water, and vermin.
- Doubling of medication/prescription complaints, insufficient weekend mental health team cover, and delays in the health needs analysis.
- Inconsistent delivery of the key worker scheme (11.08% compliance) and underrepresentation of ethnic minority staff.
- Concerns over resettlement planning, specifically for accommodation and employment on release, and the unsuitability of premises for disabled prisoners.

- The gymnasium, designed for 15 prisoners, is inadequate for a population of 1720, requiring conversion of workshops.
- There is no central laundry facility for large items, leading to costly transport to another prison.
- Domestic-standard washing machines and other electrical items on house blocks frequently require repair and have a limited lifespan.
- There is a significant shortage of office space, with some staff working in cupboards and the IMB office located outside the secure zone.
- On-site healthcare ceases at 7pm, with no residential unit, forcing prisoners with severe mental health needs or requiring palliative/24-hour care to be accommodated on wings or in the CSU.
- The library's location is poor, leading to congestion and noise, which hinders studying prisoners.
- Cell window design is flawed, leading to deliberate damage and security risks, as ground floor windows lack bars.
- Cell furniture made of MDF is easily damaged, necessitating frequent repairs and rendering cells uninhabitable.
- The Care and Separation Unit (CSU) has insufficient cells for the prison's population, with additional cells on G block converted to meet demand.
- Perimeter fencing around house block yards lacks razor wire, creating a security risk through climbing.
- Ongoing staff retention issues and inexperience are impacting the regime and increasing pressure on staff.
- Employment opportunities and education places are insufficient for the prisoner population.
- The Offender Management Unit (OMU) is understaffed, creating a backlog of offender assessments (OASys) for category reviews.
- Self-harm and violence incidents have increased with the rise in prisoner numbers.

- House block 5 poses an intolerable fire safety risk, with a high likelihood of fire and extreme consequences for life safety, requiring urgent action.
- The quality of accommodation continues to deteriorate, with dirty/broken showers, insect infestations, heating breakdowns, and inadequate maintenance.
- Inconsistent reception and induction processes for new prisoners lead to kit shortages and difficulties with phone access.
- Self-harm incidents have risen significantly, and use of force incidents have increased, with black prisoners disproportionately affected, while independent scrutiny of UoF and DIRFs is lacking.
- The key working scheme is insufficiently developed, with low attendance rates, and the cessation of the Listener scheme compromises safer custody efforts.
- Education attendance is unacceptably low despite good teaching quality, and there are limited opportunities for purposeful work-based training or using prisoner labour to improve the prison environment.

- The persistent incursion of illicit items, including dangerous drugs, leading to debt, bullying, and health issues.
- Insufficient and uninspiring purposeful activity that falls below Category C standards and does not prepare prisoners for release.
- Inadequate preparation for release for prisoners leaving directly from Aylesbury, risking reoffending and public safety.
- A deleterious imbalance between experienced and inexperienced staff, impacting induction quality, prisoner support, and potentially increasing use of force incidents.
- Long waiting times for GP (3 weeks) and dental (13 weeks) appointments, leading to prisoner complaints.
- Overstretched Offender Management Unit staff due to significant vacancies, hindering sentence planning and progression.
- Inadequate provision of secure hospital beds for prisoners with severe mental illness, placing undue pressure on prison staff.
- Disproportionate representation of Black and Muslim prisoners in adjudications, with lower rates of dismissals, suggesting potential inappropriate use of the disciplinary process.
- Frequent loss or misplacement of prisoner property, particularly during transfers.
- The age and layout of the prison building, including unreliable heating and inadequate adaptations for disabled prisoners.

- The critically low number of IMB members (three against an establishment of 16) and the inadequate recruitment process, significantly hindering the Board's statutory duties.
- Persistent issues with cell sharing in unsuitable conditions and the estate-wide poor management of prisoner property on transfer, both noted as repeated concerns from previous reports.
- The absence of IT systems for managing internal complaints, contributing to a high volume of paper-based complaints and a significant staff workload.
- Continued concerns regarding healthcare provision, including the lack of 24-hour on-site services, insufficient resources, weak governance in medicines management, and long waiting times for physiotherapy, podiatry, and optician appointments.
- Inadequate funding for the repair and replacement of gym equipment, along with the unresolved issue of a leaking workshop roof, affecting purposeful activity and the estate.
- Insufficient provision of English, maths, and ESOL education, coupled with the absence of a comprehensive reading strategy, highlighted by an Ofsted inspection.

- Persistent violence and the presence of improvised weapons, leading to staff and young people sustaining injuries during restraints.
- An unpredictable and limited regime, poor communication, and inadequate time out of cell, especially for separated young people.
- Significant shortfalls in education provision due to recruitment/retention issues, substantial lost hours, and lack of access to teaching staff for young people.
- Inadequate support for vulnerable young people, including those serving long sentences, looked-after children, and remanded young people who cannot access interventions.
- Staffing challenges such as the frequent redeployment of specialist intervention teams (e.g., Conflict Resolution, MMPR, CuSP), high sickness rates, and concerns about staff mental health and support.
- Continuing issues with estate maintenance, including areas in urgent need of refurbishment (e.g., Keppel, healthcare department) and unsuitable, grim rooms on Benbow.

- Chronic overcrowding and high prisoner turnover hinder rehabilitation efforts.
- Significant staff shortages and high turnover negatively impact almost every aspect of the prison.
- The prison remains a violent and unsafe environment for both prisoners and staff, with self-harm and assaults remaining high.
- Many cells designed for single occupancy are occupied by two prisoners, and much of the prison shows signs of dilapidation.
- Issues persist with the quality and quantity of food, and defective kitchen/servery equipment needs repair or replacement.
- A great deal of prisoner property continues to go missing during transfers and within the prison.
- A large number of prisoners are released homeless and are subsequently recalled to prison within a short period.
- There has been a significant decrease in key working sessions.

- Persistent court backlogs leading to increased and prolonged remand populations.
- Significant increase in self-harm and violence incidents, exacerbated by crowding and cell sharing.
- Lack of adequate mental health services and suitable environments for unwell prisoners.
- The outdated prison estate, including critical equipment past its design life and lift outages impacting vulnerable prisoners.
- Absence of IT systems for prisoners, leading to inefficiencies and reduced skill development.
- The abandonment of key working due to population pressures and staffing challenges.
- Inadequate family contact provisions, including insufficient social visit sessions and the lack of a child contact room and basic visitor refreshments.

- The impact of prison population pressures on Category D prisons and their resettlement programmes.
- Prioritisation of maintenance work at Hatfield Lakes site due to management by an adjoining prison.
- Discrepancies in available accommodation quality within the prison, particularly concerning refurbishment at the Lakes.
- Potential difficulty in continuing staff initiatives due to increased prison population changes.
- Ongoing need for continuation of bathroom facilities refurbishment, particularly at the Lakes where some ablutions are not fit for use.
- Ongoing completion of the new 'anti-dash' fence to improve security against illicit items.
- Delay in the commencement of the new multi-faith centre until 2025.
- Prisoners' reluctance to make applications to the IMB and a pervasive belief that complaints or DIRFs lead to return to closed conditions, despite data showing no correlation.

- Men and women remained detained together at Larne House, despite previous recommendations and Home Office acceptance, indicating a failure in safety culture.
- Accommodation at airport and reporting centre holding rooms is unsuitable, lacking natural light, ventilation, privacy, and adequate sleeping facilities.
- Healthcare provision is inconsistent and varies by location, with serious risks posed by the continued removal of prescription medication from detainees.
- Detainees are held for longer than necessary due to systemic inefficiencies in organising asylum accommodation and transfers.
- Facilities are not fully accessible for wheelchair users or individuals with sensory/non-visible disabilities.
- The Home Office lacks transparency in publishing performance metrics, internal assurance, and contract monitoring activities.
- Late-night moves involving families and children, particularly via taxis, raise concerns about potential medical emergencies.

- The ongoing issue of re-sentencing IPP prisoners, many held beyond their tariffs, with previous responses deemed inadequate.
- The absence of a national minimum wage for prisoners, leading to disparities in pay versus canteen costs.
- Insufficient work and activity opportunities for the existing prisoner population, with concerns about further increases in numbers without corresponding provision.
- The lack of additional funding for the Prison Employment Lead despite Bure performing resettlement functions, unlike designated resettlement prisons.
- The absence of CCTV in the prison, contributing to some prisoners feeling unsafe.
- The archaic, longhand recording method for adjudications, hindering Governor observation and communication, and the need for audio/visual recording.
- An observed increase in self-harm incidents that requires investigation by the prison.
- Continued underuse of education and workshop classes due to conflicting healthcare appointments and activities.
- Prisoner confusion regarding property rules, particularly for items like Xboxes, requiring clearer communication on reception.

- The disproportionate number of IPP prisoners at Whatton and the lack of policy review to support their wellbeing and morale.
- The inadequacy and delayed improvements of B wing accommodation, which is not fit for purpose with issues in size, ventilation, heating, and in-cell toilets.
- Long waiting lists and delays for prisoners to access specialist courses, potentially impacting their release dates.
- The difficulty in finding suitable employment placements for prisoners convicted of sexual offences upon release, leading to low employment rates.
- The practice of gathering visitors outside the security area and allowing entry as a group, which may not offer the full amount of time for the actual visit with the prisoner.
- The excessive detention of prisoners with severe mental health problems in the Care and Separation Unit (CSU) while awaiting transfer to specialist facilities, with one case noted at 80 days.
- The old and concerning fabric of healthcare facilities, particularly the narrow corridors causing issues for medicine collection queues.
- Staffing shortages in offender management, with only three case workers handling 200 cases when eight are typically required.
- Limited awareness among prisoners of how their allocated activities align with their long-term goals.
- A large percentage of applications from prisoners relating to property lost or not arriving during transfers.

- Prisoner-on-prisoner assaults increased during the reporting year.
- Large numbers of prisoners were returned to closed conditions, including from the TPRS scheme.
- Ongoing issues with illicit substances persisted despite enhanced security measures.
- The Temporary Presumptive Recategorisation Scheme (TPRS) severely impacted the regime, resettlement services, and staff capacity.
- Purposeful activities and access to education were curtailed due to low staff numbers and redeployments.
- Prisoners expressed concerns about sentence progression and lack of communication.
- Issues with building maintenance, including heating, hot water, and the need to remove unused buildings for safety.
- Lack of in-cell telephony prevented confidential prisoner conversations.
- Workload on the Offender Management Unit (OMU) from TPRS and ROTL processes hindered progression.
- A number of prisoners were released without settled accommodation for the first time, often due to minimal resettlement planning for TPRS arrivals.

- The Board is very concerned about future leadership and the need for high-calibre leadership to maintain progress.
- Poor prison fabric, including leaking roofs, failed heating, broken lifts, and overdue shower refurbishments, significantly impacts prisoner morale and access.
- Disproportionate use of force against black and mixed-ethnic prisoners, and generally high use of force compared to comparator prisons, remains a significant concern.
- High levels of self-harm and violence persist, and there were five deaths in custody during the reporting year.
- A critical shortage of single cells leads to inhumane cell sharing and inadequate time out of cell for many prisoners, posing a safety risk.
- Ongoing challenges in securing adequate provision of basic kit (clothes, bedding, towels) for prisoners, particularly in the first night centre.
- The Care and Separation Unit (CSU) inappropriately houses vulnerable and neurodiverse prisoners for whom no suitable alternatives exist.
- Extreme pressure on secure mental health beds in the region results in long waiting times for transfers and prevents the acceptance of mental health prisoners from other establishments.
- Chronic staffing problems in primary care, an over-reliance on agency staff, and severe staff shortages in drug and alcohol treatment teams negatively impact healthcare delivery.
- Too many prisoners spend excessive time on remand and many sentenced prisoners remain at HMP Birmingham when they should have progressed to other establishments, hindering rehabilitative work and family relationships.
- The prison is failing to meet its target for key working sessions, with only 38% of prisoners receiving weekly sessions on average.

- Overcrowding and the poor physical environment, including the lack of in-cell sanitation on B wing, in the Victorian prison.
- Insufficient support for prisoners on release, particularly regarding accommodation and community services, contributing to reoffending and recalls.
- Limited mental health services, which primarily focus on the most serious cases, leaving many prisoners without adequate support.
- The need for ongoing support for staff retention and regular recruitment to maintain improved staffing levels and prevent future shortfalls.
- The absence of essential information technology for prisoners, which hinders online applications, increases frustrations with paper systems, and consumes staff time.
- The high prevalence of illicit items contributing to safety issues, debt, self-harm, and violence, requiring additional resources to tackle.
- Inconsistent and untimely provision of reports and information to the IMB, which impedes monitoring activities.
- Concerns regarding the adequacy of the healthcare contract with Oxleas NHS Foundation Trust in meeting the diverse needs of prisoners.
- Key working is currently focused only on high-risk prisoners and is not yet available for the entire prisoner population.

- Overcrowding, leading to doubling up in cells designed for one individual, impacts decency and the ability to transfer prisoners for training.
- Serious shortcomings in HMPPS management of the poorly planned early release scheme, relying on overworked OMU staff without increased resources.
- The Prison Service struggles to attract staff due to uncompetitive remuneration, training, and professional development.
- Protracted waits for mental health transfers and inadequate mental health staffing to treat the high caseload.
- Poor service from external suppliers, particularly Serco, impacting prisoner transport and transfers.
- Inadequate accommodation to segregate different prisoner cohorts appropriately.
- Ventilation issues on Beaufort wing during hot weather and the closure of in-house laundry facilities remain unaddressed due to lack of funding.
- Key work sessions have not increased for all prisoners due to staffing shortages, limiting relationship building between prisoners and staff.

- Overcrowding, with 69% of prisoners sharing single cells, contributing to damp and mouldy conditions in the Victorian wings.
- Poor processes for safeguarding prisoners' property, particularly during internal transfers, leading to significant losses and lack of accountability.
- Significant challenges in accessing healthcare, including lengthy waiting lists for opticians and general practitioners, and delays in mental health transfers.
- The continued high level and increase in use of force incidents.
- Haphazard and delayed awarding of educational and work qualifications, alongside limited meaningful activity for some prisoners.
- Slow and unsatisfactory telephone PIN approval processes, hindering essential family contact.

- Uncertainty over the future of HMP Dartmoor and lack of communication, highlighting delayed HMPPS response to Radon gas risks and potential non-compliance with safety regulations.
- Persistent issues with Ministerial accountability, including overdue strategies (Ageing Population) and reports (IPP), and a perceived lack of credibility in responses to IMB findings.
- Deterioration of the prison estate (damp, mould, pests) and the continued inhumane practice of double-celling.
- Significant challenges in healthcare, including long waits for external appointments, lack of 24-hour care, and difficulties matching services to an ageing population, exacerbated by population changes.
- An inconsistent and often poor regime, with many prisoners not engaged in purposeful activity, affected by staffing shortages in education and industries, and arbitrary time out of cell.
- A lack of confidence in the discrimination reporting system and ongoing problems with the timeliness and quality of responses to prisoner complaints.

- The high number of deaths in custody, designating HMP Leeds a ‘cluster’ site.
- Persistent overcrowding, leading to undignified shared cells with inadequate ventilation, temperature control, and privacy, a concern highlighted for many years.
- Lack of clarity and progress for IPP prisoners, resulting in feelings of hopelessness and negative impacts on their mental health, a repeated concern.
- Significant delays and insufficient suitable places for mental health transfers, with the gatekeeping process often exceeding 14 days.
- Illicit drugs continue to be a concern within the prison.
- Staffing issues, including new staff lacking experience, some using inappropriate language, and the OMU being under-complement, affect prisoner support and management.