HMP Bedford

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We found the Trust had improved systems to address the issues we had identified during our previous inspection although there was more work to be done. Managers and staff had worked hard to improve services for patients since the last inspection, work was ongoing and there was clear commitment to continue to make improvements. There was a new mental health team and enhanced processes in place for staff to identify, assess, monitor and manage patient risk. However, staff had not ensured all patients had been assessed and treated promptly and risk assessments and care plans lacked clarity for some patients. Healthcare related incidents involving self-harm were not reported by staff.

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

Incidents were not all appropriately reported. At the last inspection we found that a serious patient incident had not been reported or investigated. During this inspection we found that staff had not reported incidents of self-harm, this meant that appropriate investigations and learning had not taken place to improve patient safety. During the period 01 March and 31 August 2024, 2195 self-harm incidents had occurred, some of these incidents may have occurred whilst the patient was receiving input from the healthcare team. However, none of these had been reported in line with the trust’s incident reporting.

At the last inspection there were 22 patients with identified mental health needs and many patients who had mental health needs were assessed as not requiring mental health care and treatment or intervention. During this inspection, management provided evidence to show that there were 215 patients with identified mental health needs. Managers and staff informed us there was a new process in place to identify and assess patients who required support from the mental health team. A mental health nurse now worked on reception alongside the primary care nurse. There was a new duty nurse role to review and process referrals each day.

There was a clear referrals process for mental health. Most patients had access to mental health care, treatment and support when they needed it, however, this system had not worked for a small number of patients. At the last inspection the trust did not have clear processes in place to ensure there was a suitable triage system in place or that mental health needs were met consistently. During this inspection, the trust had revised their triage system to ensure patients with urgent and routine needs were reviewed and assessed promptly. The trust had also reorganised staffing arrangements to ensure a mental health nurse was available at reception to identify patients with mental health needs and ensure they were referred into the mental health team. The trust had also revised their triage system to ensure referrals to the mental health team were reviewed promptly. A nurse held an emergency radio and responded to both physical and mental health emergencies. Routine referrals were assessed by the duty nurse within 5 working days. However, from a random selection of patients with potential identified mental health needs since July 2024, we found that whilst many patients had been assessed promptly, some patients had been assessed as requiring support and yet, we were unable to see that either they had received the support required or there had been a delay in them receiving support. This had resulted in 2 patients not receiving an assessment in full until they were transferred to the CSU, with minimal support available once the mental health team were aware of them. One patient had been assessed as not requiring input from the mental health team, despite the patient records indicating that they displayed behaviour consistent with poor mental health. We shared our concerns with the provider who assured us that these patients would receive the care and treatment they needed.

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

Staff assessed individual patient risk, although these assessments were not always completed promptly, interventions to mitigate risk were not always clear and these did not take place for some people. At the last inspection we found that most mental health risk assessments and care plans were not reflective of their individual needs. During this inspection, we found this had improved, although some care plans and risk assessments were generic or risks, goals and interventions were not clear. For example, 1 patient was identified to have a risk of self-harm and suicidal behaviour but there was no clear plan of care or how the patient would be supported by the mental health team. One patient with significant risks and confirmed multiple mental health diagnoses, did not have a clear plan of care, interventions were documented as required but not provided. Another patient had identified needs but with no clear plan or details of intervention of how they would be supported to improve their mental health.

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

The judgement for Safe and effective staffing is based on the latest evidence we assessed for the Safe key question.

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

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