Why Failure Must Be Explained

By Mark Leech

Yesterday I was taken to task for not being positive enough when I wrote about HMP Garth where, following (unusually) an announced HMIP inspection, it was revealed the prison had high levels of drugs and violence, where in terms of the four Healthy Prison Tests, safety had crept up from 1/4 to 2/4, respect from 2/4 to 3/4 and both purposeful activity and release planning had stalled at 3/4 since the last inspection two years ago.

It was said that I did not give enough credit where it was due.

Well that is certainly one view and one with some value to it, but on the other side of the coin Garth was also a prison where 56% of all the HMIP recommendations made and accepted by the prison two years previously had not been achieved at all.

Its really important that staff are given credit for progress, but those same staff also need to be able to take reality on the chin too – once we start to view a 56% failure rate on implementation as something to be proud of, something for which to quote one member of staff at Garth they should be given a ‘pat on the back’ for, then there is a real danger in my view that we are celebrating failure not success.

Mistaking failure for progress just skews reality; implementing 75% or 80% of HMI recommendations deserves praise, but when that drops to less than half, to just 44% that ought to be viewed as a cause for concern not credit – or the danger is that it becomes accepted as normalised and that must never be the case.

Personally I would like to see every Governor who has failed to implement 50% or more of HMI recommendations being required to publicly explain to the Prisons Inspectorate, in a written document that appears in an Annex to the Report, exactly why in two years they have been unable to do better.

There are two sides to every story and one story is only good until another one is told – if nothing else if provides an opportunity to explain the reasons why more progress wasn’t made and I imagine some would be surprised at the reasons given which currently remain hidden from view.

If the Justice Secretary has to explain publicly what has gone wrong and what he will do to put it right when faced with an HMI Urgent Notification, the same principle of accountability should apply to Governing Governors too: they too have their story to tell – and they ought to be allowed to tell it.

The buck stops on their desk and with it credit for success and responsibility for failure too.

Mark Leech is the Editor of The Prisons Handbook for England and Wales @prisonsorguk

HMP SWALESIDE – Safer and more respectful, but weaker on activity and rehabilitation

Published 8th May 2019

The Chief Inspector of Prisons has said that HMP Swaleside, a training prison on the Isle of Sheppey in Kent holding many men serving long sentences for violent offences, had ‘become safer and more respectful over two years’ – despite the fact that outcomes for prisoners against the safety prison test ‘were not sufficiently good.”

Swaleside prison, which opened in 1988, is located on the Isle of Sheppey in Kent. Covering mainly London and the South-East, the South-West as well as Wales, the prison first opened with four wings, adding four further wings between 1998 and 2010. In 2010, a psychologically informed planned environment (PIPE) unit was built, along with a pre-PIPE unit for prisoners with personality disorders and very challenging behaviour.

The prison held a complex population, including a psychologically informed planned environment unit, a wing holding prisoners seeking protection, a wing for prisoners convicted of sexual offences and a lifer wing. About a third of prisoners were serving an indeterminate sentence. Eighty-five per cent of prisoners potentially needed multi-agency supervision on release. Seventy-five per cent of the population had been assessed as presenting a high risk of harm. About 60% of prisoners had committed a violent offence. Thirty-five per cent of prison officers had been in the Prison Service for less than 12 months. One hundred and eighty-eight prisoners were employed as wing workers. Two hundred and eight-seven prisoners, about a quarter of the population, were unemployed.

Safety: Early days arrangements were generally good and prisoners were kept safe. The number of violent incidents was high. Innovative work to combat violence was promising but not yet fully productive and required more coordination. Too many prisoners in our survey said that they felt unsafe.

The number of adjudication charges had increased but processes were fair. Levels of use of force were high but oversight was generally good. Prisoners were routinely stripped of their clothing on entering the special cell, which was sometimes used without sufficient justification. The use of segregation was high and some prisoners spent a long time on the unit. Some of the work to help these individuals was impressive.

Security arrangements were generally  proportionate. Levels of self-harm were comparatively low but five prisoners had killed themselves since the previous inspection. there was some good, innovative work to help those with complex needs. The mandatory drug testing positive rate was high, at 25%, but work to reduce the supply of drugs was having some success.  

Outcomes for prisoners against this healthy prison test were not sufficiently good.”

At the last inspection in 2016 we found that outcomes for prisoners in Swaleside were poor against this healthy prison test. We made 12 recommendations in the area of safety At this inspection we found that nine of the recommendations had been achieved, one had been partially achieved and two had not been achieved.

However, progress was assessed as “lop-sided” because the quality of purposeful activity remained insufficiently good since the previous inspection in 2016 and rehabilitation and resettlement work was now assessed as poor, the lowest assessment.

Peter Clarke, HM Chief Inspector of Prisons, said that although the population was comparatively settled “Swaleside is unquestionably a difficult place to run and an institution that presents many risks.”

In 2016, it was found to be “dangerous” and safety was assessed as poor. In December 2018, it still suffered high levels of violence and too many men felt unsafe. But inspectors also found very good work to reduce the supply of drugs, a significant effort to improve safety and some impressive care for those at risk of self-harm. The overall assessment of safety rose from poor to ‘not sufficiently good.’

Relationships between staff and prisoners were generally very good, with over 70% of men saying they thought staff treated them with respect. Many staff were, however, quite inexperienced and some lacked the confidence to challenge poor behaviour.

Most cells were well maintained but the standard of cleanliness “did not correlate with the plethora of supposed prisoner cleaners.” The report noted: “During our night visit, we saw rats in corridors near rubbish bags that had not been disposed of correctly. There was an excessive number of prisoners supposedly employed to clean but the lack of effective staff supervision resulted in little cleaning actually taking place.”

Inspectors found 32% of men locked in their cell during the working day – an improvement on 2016 but still poor. Good standards of work were evident in many aspects of education, skills and work and, for those engaged, the achievement of qualifications was high. This was undermined, however, by poor allocation to activity, under-employment, poor attendance and poor punctuality.

Mr Clarke added: “Core tasks of a prison that manages the type of prisoner held at Swaleside are meaningful sentence management, the reduction of risk of harm and ultimately the protection of the public. In these tasks Swaleside was failing badly.”

Public protection arrangements were weak and offending behaviour interventions were limited, especially for the prison’s population of sexual offenders. More than 160 men convicted of sex offences were moved to Swaleside at the end of 2016 in an attempt to stabilise the jail.

Overall, Mr Clarke said:

“There was much to commend at Swaleside. Managers were energetic, caring and innovative, and staff, though inexperienced, were proactive and helpful. Improvements were clearly to be seen, as reflected in our assessments. That said, many improvements were undermined by failings elsewhere…While there had been some incremental improvements in safety, many prisoners were not fully engaged in the regime and some prisoners’ rehabilitation needs were not being met. Managers need to take a step back and think carefully about how they will not only sustain and integrate their achievements but also take a holistic approach to improving outcomes across all four of our healthy prison assessments.”

Phil Copple, Director General of Prisons at HM Prison and Probation Service (HMPPS), said:

“I am pleased that inspectors recognise the improvements that have been made, along with the energy and care that Swaleside staff put into what is acknowledged as their particularly challenging work. Clearly more still needs to be done to address violence and give prisoners more time out of their cells in education and training. Improved safety procedures have been introduced and the prison will also benefit from the new education framework we have implemented across the country to help offenders use their time in custody constructively.”

Mark Leech, Editor of The Prisons Handbook for England and Wales writes:

Swaleside has a complex and difficult prison to manage population, the improvement in safety and respect is very welcome  but the stalling of purposeful activity and the fall in release planning shows a prison where far too much focus is set around getting basic control.

Swaleside demonstrates a prison that sees itself as a destination and not a journey, its focus is on getting through each day and with the reality of release for many some years away, the end of sentence planning is not in sharp enough focus and it needs to be – focus on release planning should begin right at the start of the sentence, tentatively in these cases but it must be there if light is to seen at the end of each tunnel,

Purposeful Activity: Too many prisoners were locked in their cells during the working day, and prisoners spent far too long in their cells at weekends. The library and gym facilities were good. The leadership and management of education, work and skills required improvement. Too many prisoners were not allocated to activities. The quality of most teaching and instructing was good but there was too little accredited training in workshops. Not enough prisoners improved their employment skills. Prisoners’ attendance and punctuality were not good enough. Outcomes and achievements for prisoners were reasonably good. Outcomes for prisoners against this healthy prison test were not sufficiently good.

Release Planning: Prisoners now had telephones in their cells, which was appreciated and helped them to maintain contact with families. Visits arrangements were generally good but sessions did not always start on time. The strategic management of reducing reoffending was poor. Too many prisoners did not have an up-to-date assessment of their risks and needs. Offender supervisors had little contact with prisoners, most of which was reactive. Arrangements to protect the public were weak. Categorisation processes were adequate. There were too few places on offending behaviour programmes to meet the needs of the population, and none specifically for prisoners convicted of sexual offences. Not all prisoners were moved to a resettlement prisons before release. Outcomes for prisoners against this healthy prison test were poor.

Read the Report


HMP GARTH – high levels of violence and a daunting drugs problem found at this announced inspection

Published 9th May 2019
Leaders and staff at HMP Garth, a training prison in Lancashire, were commended for their work to reduce drugs and violence since inspectors found it in 2017 to be one of the most unsafe they had seen.

  • Note: For this Inspection, unusually, the prison had been given prior warning of the Inspection and had the been able to prepare for it in advance.

HMP Garth opened in 1988. A category B men’s establishment, it is part of the newly formed long-term and high-security estate directorate, holding a complex population. The population was predominantly made up of convicted adults serving more than four years and those serving indeterminate sentences. In addition to the mainstream residential accommodation, the prison had a number of specialist units: The Beacon Unit, offering the offender personality disorder pathway service; The Building Hope Unit, a psychologically informed therapeutic environment; a substance misuse therapeutic community and a residential support unit.

Almost all prisoners in HMP Garth were serving prison sentences of longer than 10 years and 89% presented a high risk of harm to others. Sixty-three per cent of prisoners had been convicted of serious violent offences and almost a quarter had been convicted of sexual offences. Just over a third of prisoners were serving an indeterminate sentence. In our survey, 60% of prisoners said it was easy to get hold of illicit drugs, and about one in four said they had developed a drug problem while being at HMP Garth. HMP Garth had a nationally resourced offender personality disorder pathway (OPDP) service operating from The Beacon Unit.

Peter Clarke, HM Chief Inspector of Prisons said: “It is pleasing to be able to report that in the space of two years [since January 2017] there had been significant improvements at the prison.

  • High levels of violence but slowing

“Although there was still too much violence, it had not risen in line with the overall trend across the prison estate, and credit is due to the staff at Garth for working hard to understand and contain it. There is absolutely no room for complacency, but there were some early encouraging signs of improvement.

  • Drugs: the scale of this problem was daunting

“As with many other prisons, the ready availability of illicit drugs drove much of the violence, and the scale of the challenge in this respect at Garth was daunting. Sixty per cent of prisoners told us it was easy to obtain drugs, 30% were testing positive for drugs and around a quarter had developed a drug habit since entering the prison.” Drugs and violence reduction strategies must be kept under constant review to maintain the progress.

  • Long-term, high risk population,

Garth held just over 800 prisoners, the vast majority serving sentences of more than 10 years and presenting a high risk of harm. Around two-thirds had been convicted of serious violence and a quarter were convicted of sexual offences.

  • Slight improvements in safety and respect

The poor safety assessment in 2017, in a jail in which drugs and violence then dominated the men’s lives, led inspectors to make it subject to one of only a handful of announced inspections. By late 2018, safety had risen from a poor assessment to not sufficiently good. Respect rose to reasonably good and purposeful activity and rehabilitation and resettlement remained at that level.

Mr Clarke said: “My confidence that the prison can continue to make progress was strengthened by what I saw and heard during my meeting with the senior management team. It was very clear to me that they worked together in a highly collaborative way to address the serious challenges faced by the establishment.

Members of the team, from whatever specialised function, were eager to contribute to what their colleagues were trying to achieve in their particular areas of responsibility. It was heartening to see this approach and to experience the obvious enthusiasm.”

  • Serious concerns about cancelled hospital appointments and Public Protection

Although the assessment of respect had improved, there was serious concern about the high cancellation rate for external hospital appointments. Inspectors were also concerned about some weaknesses in managing the potential risks to the public posed by those few prisoners who were released from Garth.

Overall, Mr Clarke said:

“The leadership of HMP Garth were keen to point out to me that there were early signs of improvement, and it was to their credit that what had been achieved was sufficient to raise our assessments in two of our healthy prison tests. Given the overall context in which establishments such as Garth have been operating over the past few years, this is an achievement that should not be underestimated.

For the future, dealing with the twin scourges of drugs and violence will be the key to making further progress, and I hope that when we next inspect HMP Garth we will be able to report that the momentum we saw on this occasion will have been maintained.”

Phil Copple, HM Prison and Probation Service (HMPPS) Director General of Prisons, said:

“It is extremely encouraging to see significant progress being made at HMP Garth, and I echo the Chief Inspector’s confidence that the hard work of the prison officers in the establishment will maintain this going forward. The prison continues to tackle drugs and violence head on, ensuring that prisoners can focus on rehabilitation, and I’m delighted to see that their efforts are leading to real improvements.”

Mark Leech, Editor of The Prisons Handbook for England and Wales writes:

I’m the first to give governors and staff a pat on the back for progress, encouragement is vital, but so too is reality.

To talk about ‘commendable improvements’ in a prison that still has serious problems with drugs and violence, where self-harm is very high and where less than half of the safety recommendations  made two years ago have still not been implemented, to me is is premature and to value its progress too highly.

Inspectors said:

“At the last inspection in 2017 we found that outcomes for prisoners in Garth were poor against this [Safety] healthy prison test. We made 13 recommendations in the area of safety. At this inspection we found that six of the recommendations had been achieved and seven had not been achieved.”

This was an average report, and I would have expected more progress given that the prison knew of the Inspection months in advance and were able to prepare for it – the fact that they could not do better suggests the prison is fighting a losing losing battle on a number of serious fronts.”

Read the Report 


Bronzefield Prison: Increasingly challenging population but an overwhelmingly safe prison

HMP Bronzefield in Surrey, the largest women’s prison in Europe, was found to have outcomes for the prisoners which were reasonably good or better across HM Inspectorate of Prisons’ healthy prison tests.

 With a capacity of up to 557 prisoners, and opened in 2004, the Sodexo-operated jail holds women ranging from those on remand to those considered as requiring high security restrictions.

 Mr Clarke, HM Chief Inspector of Prisons, said: “This was our first inspection of Bronzefield since 2015 and, as we did then, we found the prison to be an excellent institution.” Bronzefield was an “overwhelmingly safe prison.”

 However, the population had “become more challenging in recent years, with many experiencing significant mental health problems.” Nearly 70% of prisoners in the inspection survey reported having a mental health problem.

“Recorded violence had increased markedly since our last inspection (in 2015) but most incidents were not serious. Arrangements to reduce violence and support victims required some improvements, although weaknesses were mitigated by some very strong informal support offered to prisoners.”

An investigation by the Prisons and Probation Ombudsman (PPO), following the self-inflicted death of a woman in 2016, had raised significant criticisms, but recommendations made by the PPO had been addressed. Self-harm among prisoners remained high, but overall the care for those in crisis was good.

Bronzefield had a clean and decent environment and its key strength was the quality of staff-prisoner relationships. “Most prisoners felt respected or had someone they could turn to for help. The interactions we observed were impressive. The promotion of equality was appropriately prioritised” Mr Clarke said.

Most prisoners had a good amount of time out of cell and there were sufficient activity places for all. Education, skills and work provision had improved considerably, while achievement among learners had also improved. Ofsted inspectors judged provision to be ‘good’ with some outstanding features.

Work to support rehabilitation and release planning would have benefited from a more comprehensive needs analysis but, despite this, the quality of offender management and the effectiveness of resettlement planning were good and public protection work robust. The high standard of family support was commended as good practice.

Mr Clarke said:

“Bronzefield seemed to us to be meeting nearly all its key objectives. There was work to do – a priority being the reduction of violence – but the overall success of the prison was built on healthy and supportive relationships and the knowledge and understanding the Bronzefield staff had of their prisoners, many of whom had high and complex support needs. In addition to the prison being a safe place, prisoners were treated with care and respect and were helped to progress through their sentence ultimately to the point of release. We leave the prison with a small number of recommendations we hope will assist in further progression and congratulate the managers and staff on what they have been able to achieve.”

Phil Copple, Director General of Prisons, said:

“It is clear that staff at Bronzefield are doing great work to help give women, who often have complex needs, all the tools they need to turn their lives around.

“That work includes supporting them through substance abuse and mental health issues, and ensuring they can get education and training that will help them on release.

“In common with other women’s prisons incidents of self-harm and violence remain a concern, but I am pleased to see the governor and his team put in strong mechanisms to reduce this.”

Read the Report

HMP ONLEY: A chaotic, fundamentally unsafe, prison locked in a battle with drugs and violence.

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“This is a truly shocking report of a prison in complete chaos and in danger of flipping into self-destruct – the lack of Urgent Notification from the Prisons Inspectorate is frankly bewildering.”
Mark Leech

UPDATE:  Mark Leech: Following publication of this post today, and my comments at the bottom of it, I received a juvenile email from the Chief Communications Officer at The Prisons Inspectorate – you can read it, and my reply, here

HMP Onley, a training prison in Warwickshire with 80% of its population from London, is “fundamentally unsafe” with high levels of drugs and violence.

When the Prisons Inspectorate last inspected HMP Onley in 2016 they made 70 recommendations overall. The prison fully accepted 53 of the recommendations and partially (or subject to resources) accepted 16. It rejected one of the recommendations.

At this follow-up inspection in November 2018 – two years later – the Prison Inspectorate found that the prison had achieved 24 of those recommendations, and not achieved 46 recommendations.

Peter Clarke, HM Chief Inspector of Prisons, said the prison had been assessed as ‘poor’ for safety – the lowest assessment – at the previous inspection in 2016.

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When inspectors visited in November 2018, Mr Clarke added, it was “particularly disappointing” to find Onley was still fundamentally unsafe.   “Time and again we find that prisons which are unsafe will struggle to make progress in other areas, and HMP Onley was no exception.”

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The lack of safety was “all too obvious”. The report noted that the reception wing was chaotic and “new arrivals, still carrying their property and stood in the busy corridor, were approached and faced predation by more experienced prisoners.”

 Mr Clarke added: “Perhaps it is not surprising that in our survey only 62% of prisoners said they felt safe on the first night. Sadly, their feelings were an all too accurate reflection of what life in Onley would be like during their time there.”

The prevalence of illicit drugs played a major role in causing destabilising factors such as violence, debt, bullying and health emergencies. During the previous three months there had been 200 emergency health calls related to the use of new psychoactive substances (NPS). “Despite this, we found that far too little was being done to obstruct the flow of drugs into the jail.”

Violence was higher than at similar category C prisons and although prisoner-on-prisoner assaults had decreased since 2016, assaults on staff had more than doubled. Far too many prisoners were self-isolating – refusing to come out of their cells or to go to education, work and training. The prison believed much of the violence was gang-related.

Mr Clarke said: “HMP Onley was a clear example of where the failure to deal with drugs and violence undermined many other aspects of prison life. There was a vicious circle where fear, frustration and boredom increased the demand for drugs, which in turn fuelled the violence.

“In order for Onley to break out of this circle, there must obviously be more effective action taken to reduce violence and the availability of drugs. But at the same time, more can be done in other areas.”

Rubbish was consistently thrown from cells windows and, the report noted, “there were problems with rats, and recent attempts to control the infestation had left some dying in wall cavities and vents, leaving an intolerable smell in some cells.” Accommodation on Onley’s newer wings was better than on its “shabby, cramped” older wings.

Onley was a training prison without enough activity places for the population, and during the inspection only 50% of prisoners were engaged in purposeful activity at any one time. Some 39% of prisoners were locked in their cells during the working day – far too high a proportion for a training prison. Extensive PE facilities were underused by the prison population, which was predominantly young, with around 60% from a black and minority ethnic background.

Inspectors noted that the prison had run a restricted daily regime for more than four years because of chronic staff shortages, though this was gradually being addressed.

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Mr Clarke said: “There can also be little doubt that doing more to support family relationships would help prisoners rehabilitate and prepare for their eventual release.” The report noted that Onley was in a remote location but there was no transport for families from local stations.

Overall, Mr Clarke said:

“I would not wish to detract from the many good things being delivered by dedicated and skilful staff. Health care, education, training, industry and offender management leading to release were all areas where there was some very good provision. Sadly, Onley will fail to fulfil its role as a training and resettlement prison until it can deal with the inextricably linked blights of drugs and violence.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“Tackling drugs and violence at Onley is our top priority and, while challenging, significant efforts have been made to drive improvement. These have included a major recruitment drive, with 30% more officers soon to be in place compared to 2018, along with additional security measures such as mail scanners, while a new drug recovery unit is due to open this spring. As the Chief Inspector makes clear, despite the difficulties there is good work going on at Onley to help prisoners turn their lives around and reduce the risk of reoffending on release.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said the report showed “a prison in complete chaos”.

Mr Leech writes:

This is a truly shocking report of a prison in complete chaos and in danger of flipping into self-destruct – the lack of Urgent Notification from the Prisons Inspectorate at Onley is frankly bewildering.

Onley is a fundamentally unsafe prison, previous recommendations on safety, decency, and respect have been ignored wholescale.

Drugs and violence have taken control, and Onley ticks all the Urgent Notification boxes – yet the Prisons Inspectorate has failed yet again to activate a procedure designed for exactly these kind of situations.

I have heard it suggested elsewhere that political pressure was placed on the Prisons Inspectorate to ‘give it a rest’ and not to activate the Urgent Notification procedure ‘for a while’, after four in a row were bowled stump high at the Justice Secretary last year – true or not, if Onley doesn’t meet the test for the Urgent Notification procedure, then I’d like someone to tell me exactly what does.

Mark Leech is the Editor of The Prisons Handbook for England and Wales

HMP/YOI Stoke Heath: Safe and ordered prison, but poor purposeful activity – told to get more prisoners into work, training and education

HMP//YOI Stoke Heath, a training and resettlement prison holding up to 782 male prisoners in rural Shropshire, was found by inspectors to be “overwhelmingly safe.”

Peter Clarke, HM Chief Inspector of Prisons, said the 2015 inspection of the jail had found reasonably good outcomes – the second highest assessment – against all four HMI Prisons tests of a healthy prison.

“At this inspection (in November 2018) we were pleased to find a very similar picture, despite some deterioration in the provision of purposeful activity.”

The prison remained “overwhelmingly safe”. Violence, unlike at many other prisons, had not increased since 2015, with an encouraging decrease since the summer of 2018 following a spike earlier in the year.

“Work to address violence and incentivise prisoners was reasonably good and, overall, we found a prison that was ordered and under control,” Mr Clarke added. However, use of force by staff had increased, and was high, and more needed to be done to ensure “comprehensive governance and accountability” of its use.

Inspectors found strong work to tackle drugs. The report noted that the management “made effective use of electronic security aids, including equipment to identify illicit items such as mobile phones, drugs and weapons.”

“At the time of inspection, prisoners were receiving photocopies of their domestic mail rather than the original letters sent in. Managers explained that this was in response to credible intelligence that some mail coming into the prison had been impregnated with a new psychoactive substance (NPS).” The prison planned to stop the restriction when it had scanner to detect the drugs without photocopying. Guidance for the local community to spot potential drugs-related suspicious activity was commended as good practice.

Inspectors were concerned about the prison’s response to self-harm, which had risen sharply. While prisoners in crisis said they felt well cared for, they were often left locked up for extended periods. Prisoners generally, though, expressed “real confidence” in the staff, who they saw as being in control and work to introduce a key worker scheme and an ‘active citizenship’ initiative were well advanced. Many cells, however, were very small and cramped.

A major weakness of the prison was the number of prisoners – about a third – who were inactive and locked up during the working day and there was insufficient activity for the whole population. However, achievement rates for those who attended education, vocational training or work were generally good. Rehabilitation and release planning remained reasonably good overall, thought assessments and risk management plans could improve.

Overall, Mr Clarke said:

“Stoke Heath has benefited from stable and competent leadership that has attended to trying to get the basics right. This is not to argue that there aren’t further improvements that can be made – there are many. But Stoke Heath was dealing with the same risks and challenges that other less successful training prisons face and yet it remained a largely well-ordered place where the prisoners, for the most part, trusted the staff. Good work was being done to confront the scourge of drugs and violence. The challenge going forward is to maintain these successes and build on them in a way that also integrates improvements to the prison’s regime and resettlement offer.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“Stoke Heath provides a safe and respectful regime which gives positive opportunities for prisoners to turn their lives around. As the Chief Inspector makes clear, Stoke Heath is a good prison and, whilst there is more to do to improve purposeful activity, the Governor and staff deserve credit for their achievements in a challenging operational environment”.

A copy of the full report, published on 19 March 2019, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons

HMP Lancaster Farms: A pointless Inspection Report by a Chief Inspector who doesn’t ‘Get’ the need for evidence

View Mark Leech’s: Analysis: Partially Achieved & Pointless.

HMP Lancaster Farms is a Cat C resettlement prison serving the North West of England.

Opened in 1993, the prison has an operational capacity of 560 and now holds adult male prisoners in a prison campus that contains six main accommodation units. The majority of those held were aged between 21 and 40, with most serving sentences of between two and 10 years. A smaller number of shorter-term prisoners and those serving life were also in residence. Most prisoners had arrived at the prison over the preceding 12 months.

We last inspected Lancaster Farms in 2015 when we found a prison that was reasonably safe and respectful but with more to do to improve outcomes in learning and skills as well as resettlement.

At this inspection the evidence pointed clearly to some improvement, but overall our healthy prison assessments remained the same. It was disappointing that only a third of our previous recommendations had been achieved.

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The prison continued to be a reasonably safe place. Arrangements to receive new prisoners into the establishment were generally effective and we found a prison that was calm and ordered. Levels of violence broadly reflected those seen in similar prisons but most incidents, with some exceptions, were relatively less serious. There was some evidence of prisoners intimidating other prisoners and there were several individuals who sought sanctuary either through self-isolation or in segregation.

Support for these prisoners was better than before but remained insufficient. New CSIP (Challenge, Support and Intervention Plan)1 case management and multi-disciplinary initiatives to promote improved outcomes for victims and perpetrators were encouraging but embryonic.

The use of force had increased noticeably but was poorly documented, which meant there was inadequate assurance that it was used proportionately and legitimately. Segregation was usually full, although staff were supportive and living conditions reasonable. Reintegration planning for those segregated was too limited.

Security was managed competently and proportionately. There was a good flow of intelligence, although some was not prioritised or acted upon with sufficient rigour. There was considerable evidence of a drug problem within the prison, notwithstanding a series of initiatives to combat the problem. Many prisoners thought it was easy to get hold of illicit substances and testing suggested a high but reducing positive rate.

Care for those at risk of self-harm was reasonably good, but too many lived an isolated experience and levels of self-harm were now much higher than the previous inspection. Case management was, however, reasonable and efforts to include families, if possible, were a good thing. Prisoners in crisis told us they felt well supported by staff. The prison had met all previous recommendations made by the Prison and Probation Ombudsman (PPO).

Staff-prisoner relationships in general were very good, with 84% of prisoners telling us they felt respected by staff. The lived environment was bright and spacious and outside areas were clean and well maintained. Cellular   accommodation was reasonable, as was the food, and there were reasonable attempts at formal consultation with prisoners.

Attempts to improve the way prisoners made applications were not yet, however, working effectively and the complaints process was undermined by delays. Work to improve the promotion of equality had started recently but it was too early to be sure whether this initiative would lead to substantive and sustained improvement.

Outcomes for differing groups with protected characteristics remained mixed. The provision of health care, like many other areas, was improving and was satisfactory overall, despite often long waits for access. Drug services, aided by a new well-being unit for those recovering from drug abuse, were very good.

Time out of cell was reasonable, as was access to the gym and library. There was good support for family ties and visits, thanks in considerable measure to the work of the Prison Advice and Care Trust (PACT) and Partners of Prisoners (PoPs), and there was sufficient activity for all prisoners following recent increases to the number of places available.

Despite this, many of the weaknesses identified at the previous inspection had still to be addressed. Too few prisoners attended education or work regularly or on time and cover for staff absences was insufficient, leading to the frequent cancellation of activities. Allocation to learning activity too often did not recognise a learner’s abilities or experience, and learning targets were of limited use.

Basic skills were not well supported in vocational training and shortcomings in teaching, learning and assessment all combined to limit learner progress. For those prisoners able to complete a course, however, the achievement of qualifications was high on most courses. Overall our partners in Ofsted judged the effectiveness of provision as ‘requires improvement’.

There was some improved collaborative work between departments to support rehabilitation and resettlement, but many weaknesses persisted. Many prisoners did not have an up-to-date offender assessment system (OASys) assessment or arrived at Lancaster Farms without one.

Contact with offender supervisors was too limited or reactive, and the shortage of probation staff was a concern regarding higher-risk cases and the overall quality of risk management. Some of the case work we inspected was poor. Public protection work had improved but remained insufficiently robust,  particularly concerning support for multi-agency public protection arrangements (MAPPA).

Offending behaviour work was narrow but resettlement assessments and work with those about to be released were much better.

The evidence of this inspection confirmed to us that Lancaster Farms remained a competent prison enabled by a capable management team and a generally confident staff. There was a definite sense that if you were a motivated prisoner with a determination to improve your own life chances, there were opportunities and resources that were available for you in the prison.

In contrast, if you were less motivated, you could easily opt out with too little challenge from the institution. This was a missed opportunity. Lancaster Farms was a decent enough place in comparison to many similar prisons, but it can do more and do it better.


Mark Leech, writes:
Partially Achieved & Pointless

The above summary, written by the Chief Inspector of Prisons, reveals a seriously disturbing sleight of hand that has quietly taken place in the presentation of Prison Inspection reports since Clarke became Chief Inspector – concerning ‘Partially Achieved’ recommendations, that I will come to later.

First the facts: In the four years that have passed since HMP Lancaster Farms was last inspected and the Chief Inspector made 66 recommendations to improve the prison, less than a third of those recommendations have been implemented – a fact Peter Clarke casually waves away as ‘disappointing’.

It’s not ‘disappointing’ Mr Clarke, its an absolute disgrace – and in failing to see that, so are you.

Let’s face it:  if a prison can’t implement a recommendation of the Prisons Inspectorate in four years then it’s never going to do it, is it?

The reality, when you strip away the niceties in this report is that Lancaster Farms is a violent prison, where prisoners lock themselves away, where adjudications have rocketed, where use of force has spiralled – and where the appropriate paperwork is simply not completed.

The education delivery by Novus comes in for devastating criticism and rightly so – but that criticism is from Ofsted not the Prisons Inspectorate.,

The wait to see a GP regularly exceeds four weeks, a pharmacist attends just once a week, and 79 prisoners had been waiting for up to four months to see a dentist – Lancaster Farms is a prison where safety, respect, purposeful activity and preparation for release have all been subject to ignored – and repeatedly ignored – recommendations from the last inspection four years ago.

The figure of 32% achieved recommendations means that 68% of the Inspectorate recommendations were ignored. These figures are fairly meaningless in isolation until you see exactly what those ignored recommendations actually were; take a look.

A senior manager should identify and record the exceptional circumstances to justify a prisoner on an ACCT [suicide and self harm] document being held in segregation. (1.31)
Not achieved

Segregation reviews should be meaningful and should involve the prisoner in a forum consisting of staff from relevant departments and their unit, and reintegration plans should be actively promoted where possible. (1.72)
Not achieved (recommendation repeated, 1.32)

Prescribing regimes for drug dependency should be flexible and tailored to the individual and reflect national guidance. (1.81)
Not achieved

Searches should be carried out promptly once the need is identified. (1.45)
Not achieved

The disciplinary approach adopted should be proportionate to the seriousness of the alleged offence.
Not achieved

Segregated prisoners should be able to exercise in clean open areas. (1.71)
Not achieved

There should be arrangements to process prisoners arriving during the lunch period. (1.7)
Not achieved

The needs of prisoners with protected characteristics should be identified and met promptly through monitoring, regular and direct consultation, effective use of prisoner representatives, individual assessment and when needed effective care planning. (S38)
Not achieved

All showers should be screened, kept in good condition and supplied with constant water pressure and temperature. (2.8)
Not achieved

All cells should be provided with lockable cabinets. (2.9)
Not achieved

Cells designed to hold one prisoner should not be used to hold two. (2.10)
Not achieved (recommendation repeated, 2.7)

Prisoners should be able to receive clothing sent in through the post and have quicker access to their stored property. (2.11)
Not achieved

The application process should be efficiently tracked and managed. (2.12)
Not achieved (recommendation repeated, 2.26)

There should be a paid carer scheme for prisoners with disabilities and the role of carers should be clearly defined. (2.36)
Not achieved

Older prisoners and those with disabilities should, where necessary, have an up-to-date PEEP and a multidisciplinary support plan with which all unit staff, including those on night duty, should be familiar. (2.37)
Not achieved

Waiting times for primary care services including the GP should not exceed clinically acceptable waiting times in the community. (2.72)
Not achieved

Prisoners should have access to a complete pharmaceutical service, including pharmacy-led medicine use reviews and audits. (2.84)
Not achieved

Prisoners should have access to routine dental appointments within six weeks. (2.91)
Not achieved (recommendation repeated, 2.101)

Breakfast should be issued on the day it is to be eaten. (2.105)
Not achieved

Lunch should not be served before 12 noon and the evening meal not before 5pm. (2.106)
Not achieved

Serveries should be adequately supervised. (2.107)
Not achieved

The full prison regime should be provided, more prisoners should be unlocked during the working day and men should have at least an hour a day of outside exercise. (3.7)
Not achieved

The overall quality of individual learning plans should be improved to ensure targets are clear and meaningful. (3.28)
Not achieved

All areas of the OLASS provision identified for improvement through teaching and learning observations should be dealt with swiftly. (3.16)
Not achieved

A management and monitoring system should be introduced for the cardiovascular equipment in the units and all equipment should be kept in good repair. (3.45)
Not achieved

An appropriate area should be re-established for outdoor sports and games. (3.46)
Not achieved (recommendation repeated, 3.15)

Offender management work should ensure that all prisoners have a good quality and up-to-date assessment to inform sentence planning and risk reduction work. (S40)
Not achieved

Effective use should be made of ROTL for suitable prisoners. (4.9)
Not achieved (recommendation repeated, 4.18)

Offender supervisors should have regular contact with prisoners  proportionate to their level of risk and needs. (4.21)
Not achieved (recommendation repeated, 4.17)

‘Partially Achieved’

Once again this Report highlights the deeply concerning practice introduced by this Chief Inspector in which  he claims that some of the previous recommendations he has made have been ‘Partially Achieved’  – but they are claims he makes with nothing to back them up.

Certainly other Chief Inspectors of Prisons who went before Clarke also made Partially Achieved assessments, the difference is that, unlike all others, Clarke cannot provide a shred of evidence to support these Partially Achieved assessments; confirming to me that there exists no criteria against which Inspectors can judge such assessments; telling me: “there is no set criteria. Inspectors use their judgement based on the outcomes and evidence they observe.”

The reality is that Clarke’s partially achieved assessments are devoid of evidence and as a result are totally meaningless – worse than that they are misleading as they are open to being misconstrued.

What on earth does ‘Partially Achieved’ even mean anyway?

Is that 1% achieved, 50% achieved, or 99% achieved?

Without supplying a shred of evidence to support that assessment, or any published criteria to back it it up, we have no way of knowing – this is a new and worrying development introduced when Clarke became Chief Inspector.

Here are examples, totally devoid of explanation, of how Clarke presents his PA assessments – click to expand images

Now Look at this report (image on page 19) on Lancaster Farms from 2011, these show recommendations from 2008 that were subsequently assessed as being Partially Achieved in the report published in 2011 – but each one with solid published evidence to back up the assessment; something Clarke has completely removed from his reports.

Here are some of the recommendations Clarke claims to have been  ‘Partially Achieved’  in this report – but we have no way of knowing whether they are true or false; or how true, or how false, they actually are.

Assessments, including terms of reference and meeting minutes, should be revised to ensure all high risk cases are fully considered, record keeping is comprehensive and MAPPA risk levels are identified in a timely way pre-release. (4.28)
Partially achieved

The prison should introduce effective management oversight of all public protection procedures. All prisoners should be reviewed for MAPPA eligibility and their potential risks to children, and public protection issues should be correctly recorded on P-Nomis. (S41)
Partially achieved

The achievement of qualifications in under-performing courses should be improved. (3.32)
Partially achieved

Quality improvement arrangements should be developed for the non-OLASS provision particularly for the observation of teaching, learning and coaching. (3.17)
Partially achieved

Feedback from teachers should provide prisoners with clear information on what they need to do to progress. (3.29)
Partially achieved

Custody staff should be present when medicines are being dispensed to manage queues and ensure confidentiality. (2.85)
Partially achieved

Custody staff should all be trained in basic life support and the use of the automated defibrillator. (2.63)
Partially achieved

The prisoner consultation process should ensure that effective and timely action is taken to resolve prisoner concerns. (2.17)
Partially achieved

The prison should ensure there are sufficient prison work opportunities for the population and that work skills prisoners develop are recognised and recorded. The available activity places should be used fully. (S39)
Partially achieved

Prisoners subject to ACCT procedures should have a consistent case manager and care plans should contain specific, measurable, achievable, realistic and time-bound objectives. (1.30)
Partially achieved

The establishment should ensure that all administration of medication substance misuse treatment is adequately supervised by suitably trained officers. (1.82)
Partially achieved

The prisoner consultation process should ensure that effective and timely action is taken to resolve prisoner concerns. (2.17)
Partially achieved

Custody staff should all be trained in basic life support and the use of the automated defibrillator. (2.63)
Partially achieved

Custody staff should be present when medicines are being dispensed to manage queues and ensure confidentiality. (2.85)
Partially achieved

This isn’t just semantics.
Governors who work to implement HMIP recommendations shouldn’t have their efforts assessed as ‘partially achieved’ or ‘not achieved’ at all, solely dependant on the toss of a coin as to which Inspector they get.

That’s the danger Clarke cannot see.

Peter Clarke is due to retire as Chief Inspector of Prisons in 10 months time; as a former Police Officer with 32 years service in the Metropolitan Police and no prior prison experience at all, he was never the right person for this vital statutory Independent office.

The fact that Clarke only applied to become Chief Inspector of Prisons after being telephoned personally and invited to apply for the post by the then Secretary of State for Justice (the very person who then later appointed him to independently inspect his own prisons) demonstrated in Clarke from the outset  a worrying inability to recognise what ‘independent’ actually meant.

My hope is that the next incumbent as Chief Inspector will better understand prisons, will realise that independence means what it says, that its not just a form of words but a frame of mind – and that it will be someone who will immediately roll back Clarke’s seriously defective policy of failing to provide evidence for Partially Achieved assessments he makes in official reports.

After 32 years in the Police one might be forgiven for expecting that Peter Clarke, better than anyone, would have understood the vital need to provide evidence for statements that are made – but his failure to provide any basis for his partially achieved assessments shows it was, unexpectedly, an expectation too far.

Read The Report

Mark Leech is the Editor of The Prisons Handbook for England and Wales


HMP & YOI Hollesley Bay: A successful and effective open prison

HMP & YOI Hollesley Bay, an open prison in Suffolk holding up to 485 adult  prisoners, was found to be a “very safe” jail with good or reasonably good outcomes for those detained. 

Many of those held are serving relatively long sentences of more than four years, with just over 100 serving over ten years or life. More than 100 were violent offenders. The prison was making plans to hold sex offenders, although there was much more work to do on this development.

Peter Clarke, HM Chief Inspector of Prisons, said: “We last inspected the prison in 2014, when we reported on an impressive institution. Following this inspection, we can report that the prison 

Most prisoners said they felt safe and violence and use of force by staff were relatively rare. However, there had been a “disappointing increase in the use of drugs.” The report noted: “A local analysis…had identified that prisoners had moved away from using the harmful new psychoactive substances (NPS) and that cannabis was now the preferred drug. We calculated that about 59% of all positive drug test results in the previous year had been for cannabis, with no positive results for NPS in the previous six months. The use of cocaine and steroids was an emerging problem.”

The prison, Mr Clarke added, was an overwhelmingly respectful place, underpinned by some very supportive staff-prisoner relationships, though some prisoners felt intimidated by staff and feared that they could be arbitrarily returned to closed conditions. “This was a perception that the prison needed to do more to understand and remedy.”

Prisoners had significant amounts of time out of their cells and the prison offered a wide range of educational and vocational training programmes. The prison had good relationships with regional employers and this had led to many unpaid and community positions for prisoners on release on temporary licence (ROTL).

Inspectors had one significant concern. Mr Clarke said: “In contrast to much that was happening in the prison, public protection work was not good enough. We have made this very significant failing the subject of our one main recommendation.”

The report noted: “About 10% of the prison population presented a medium or high risk of harm to children. Assessments of the risks were not always undertaken promptly enough following arrival at the prison, and contact restrictions were not always applied in the interim. The monitoring of mail and telephone contact was poor.” MAPPA management levels were not always confirmed with the National Probation Service offender manager.” Multi-Agency Protection Arrangements are designed to manage the risk from offenders released into the community.

Overall, Mr Clarke said:

“Hollesley Bay remained a successful and effective prison. The establishment was, at the time of our inspection, experiencing a time of change, with a new governor about to be appointed and plans to develop the prison’s role to hold sex offenders. Outcomes were, however, reasonably good or better and those detained were treated well. We leave the prison with several recommendations which we hope will assist further improvement.”

Michael Spurr, Chief Executive of Her Majesty’s Prison & Probation Service, said:

“I welcome the Inspectorate’s positive assessment of Hollesley Bay as an effective open prison, doing impressive work to prepare men for resettlement, often after lengthy periods in custody. The new Governor will develop this work further and the prison has already taken steps to improve public protection and implement the report’s recommendations.”

 A copy of the full report, published on 5 March 2019, can be found on the HM Inspectorate of Prisons website at: www.justiceinspectorates.gov.uk/hmiprisons 

HMP Parc Young Persons Unit: Inspectors Commend Continuing Improvement – But CSIP and Catering Issues Must Be Addressed

Inspectors visited the Young Persons Unit at HMP Parc in South Wales last October and in their Report, published on 26th February 2019, said:

HMYOI Parc is a small juvenile facility comprising two wings and holding up to 60 boys aged under 18 located in the much larger Parc prison in South Wales. The unit and wider prison are operated by the private company G4S. At the time of this annual inspection there were 37 boys in residence.

At our last inspection we reported how good leadership and a re-energised staff group had contributed to significant improvement at the establishment. It was clear on this visit that the team had continued in their efforts to make the unit safer, more purposeful and more respectful. We had previously found high levels of violence, and boys with poor perceptions of their own safety. During this inspection, perceptions of safety were much better and recorded violence was on a consistent downward trajectory, with few serious incidents. Very few boys isolated themselves in their cells or were located in the segregation unit. The leadership team had established a reward-led culture that motivated most boys to behave, incorporating an evidence-based instant rewards scheme that we considered good practice.

Child protection procedures, an area in which we have previously been critical, were now much more effective and again evidenced good practice. Similarly, the multidisciplinary case management approach to managing the victims and perpetrators of violence through the application of a nationally sponsored process known as CSIP1 was an example to the many establishments that have struggled to grasp its potential.

Our highest assessments were in the areas of respect and purposeful activity. The units were clean and well maintained, relationships between boys and staff were good, and staff were tolerant but also displayed the confidence to challenge inappropriate behaviour when necessary. They balanced authority and care to create a supportive and disciplined environment.

The strategic approach to the management of equality and diversity had improved and health care services remained good. Time out of cell was impressive, even for those on the lowest level of the rewards scheme. There had been a progressive move to establishing a whole-unit approach to managing the boys at Parc. Departments worked together in a way we do not often see. Some experienced prison officers had been supported to undertake the postgraduate Certificate in Education training to work in education, which served to break down barriers between departments.

The education unit was exceeding the performance indicators set out in its contract and boys achieved a success rate of over 90% in most qualifications.

However, we made two main recommendations, one regarding the food and the other risk management. During our inspection, we spoke to most of the boys on both units. They were quick to praise staff and were very fair about their experiences at Parc, complaining about very little. This gave considerable credibility to their consistent complaints about food. Our own observations supported their negative perceptions and we would urge the prison to meet with the contractor at the earliest opportunity to address concerns in this important area.

Our second main recommendation concerned weaknesses in the establishment’s approach to risk management. Caseworkers worked well as part of multidisciplinary teams and were particularly effective in helping to manage boys on CSIP plans. The team knew the boys on their caseloads well and contact was good. However, despite significant information about risk being available to caseworkers, it was not always recognised or sufficiently investigated to inform sentence planning and management. This meant that planning for release did not adequately consider the vulnerabilities of or risks posed by some boys on their return to the community.

Given the energy and commitment put into addressing the concerns raised at previous inspections, we remain confident that leaders at Parc will make every effort to address our recommendations.

This was a good inspection and we found that the establishment was characterised by good relationships, excellent multidisciplinary work and strong leadership.

Mark Leech, Editor of The Prisons Handbook for England and Wales writes:

There is no getting away from it this is a good report on a small unit managed by G4S, the same company that six months ago saw the Ministry of Justice step-in to Birmingham Prison, which it also then operated, because of disastrous issues of management and control.

The young person population at Parc is minute by comparison, the report is silent on the resources made available to this Unit in terms of staff profiling, a constant defect in Inspection Reports that prevent effective comparability, but this is a good report, on an often difficult to manage, volatile and vulnerable population.

Parc overall is a huge prison, one of the largest in Europe and a research report last month showed that Wales has the highest rate of imprisonment in Western Europe – despite having one of the lowest crime rates.

The rewards-based focus identified in the report demonstrates once again that more carrot and less stick is often the most effective way to achieve behavioural change, and G4S are to be commended for putting rehabilitation and reducing reoffending at the heart of their work.

The two issues identified as defective in the report must be tackled.

The issue with catering, producing food that is often cold, unappetising and the source of constant complaints – confirmed by the Inspectorate – must be a major focus now for the prison’s management; we have seen too many times how complaints about food can lead to serious unrest if the issue is not tackled effectively.

But by far the more serious issue is with the weaknesses identified with the approach to CSIP, which must be addressed as a matter of urgency. [Challenge, Support and Intervention Planning, is a system used to manage the most violent prisoners and support the most vulnerable prisoners in the system. Prisoners who are identified as the perpetrator of serious or repeated violence, or who are vulnerable due to being the victim of violence or bullying behaviour, are managed and intended to be supported on a plan with individualised targets and regular reviews.] 

My one point of caution would be that all the good work that is being achieved at this small unit at Parc risks being undone if the issue with CSIP is not addressed properly – and this takes on an even greater significance if, as seems likely at the end of their sentence, these young people are simply tossed back into the same toxic inner-city, high-crime, poor opportunity environments that they were first taken out of – but that is a societal issue for the Welsh and UK Governments as a whole to tackle, and in respect of which G4S to be fair can itself have little effect.

Read the Report

HMP Durham: Must Address Violence, Drugs and Deaths says Inspectors

HMP Durham, a heavily overcrowded prison, was found by inspectors to have significant problems with drugs and violence and worryingly high levels of self-harm and self-inflicted and drug-related deaths.

Durham became a reception prison in 2017. Around 70% of the 900 men in the jail were either on remand or subject to recall and over 70% had been in Durham for less than three months. On average, 118 new prisoners arrived each week. Significant numbers of prisoners said they arrived at the jail feeling depressed or suicidal. Self-harm was very high.

Peter Clarke, HM Chief Inspector of Prisons, said: “Our overriding concern was around the lack of safety. Since the last inspection in October 2016, there had been seven self-inflicted deaths, and it was disappointing to see that the response to recommendations from the Prisons and Probation Ombudsman (which investigates deaths) had not been addressed with sufficient vigour or urgency.

“There had also been a further five deaths in the space of eight months where it was suspected that illicit drugs might have played a role.” Drugs were readily available in the jail and nearly two-thirds of prisoners said it was easy to get drugs; 30% said they had acquired a drug habit since coming into the prison. “These were very high figures”, Mr Clarke said, though the prison had developed a strategy to address the drugs problem.

The leadership, Mr Clarke added, was “immensely frustrated by the fact that they had no modern technology available to them to help them in their efforts to stem the flow of drugs into the prison. We were told that they had been promised some modern scanning equipment but that it had been diverted to another prison.” The scale of the drugs problem and related violence meant that technological support was urgently needed.

Since the last inspection at Durham in 2016, violence had doubled and the use of force by staff had increased threefold, though some of the increase in force may have been due to new staff who were not yet confident in using de-escalation techniques. Governance of the use of force had improved.

Mr Clarke added: “There were some very early signs that the level of violence was beginning to decline, but it was too early to be demonstrable as a sustainable trend.”

Alongside these concerns, inspectors noted “many positive things happening at the prison.” These included the introduction of in-cell phones and electronic kiosks on the wings for prisoners to make applications, which had “undoubtedly been beneficial”. The disruption caused by prisoners needing to be taken to court had been reduced by the extensive use of video links.

A new and more predictable daily regime had recently been introduced, increasing access for men to amenities such as showers and laundry on the wings. “For a prison of this type, the time out of cell enjoyed by prisoners was reasonable and it was quite apparent that, despite its age, the prison was basically clean and decent,” Mr Clarke said. It was also good that the leadership saw new staff as an opportunity to make improvements, not an inexperienced liability.

Overall, Mr Clarke said:

“There was no doubt that there was an extent to which HMP Durham was still going through the process of defining, refining and responding to its role as a reception prison. The very large throughput of prisoners gave rise to the risk that taking them through the necessary processes could predominate over identifying individual needs and ensuring favourable outcomes. However, the prison was aware of this risk. The most pressing needs are to get to grips with the violence of all kinds, make the prison safer and reduce the flow of drugs. Only then will the benefits flow from the many creditable initiatives that are being implemented.”

Mark Leech, Editor of The Prisons Handbook for England and Wales said:

“Apart from security, safety must be the primary function of any prison but the number of deaths at Durham, and particularly the failure to implement the recommendations of the Prisons and Probation Ombudsman designed to reduce deaths in custody, is deeply worrying.

“Only yesterday I wrote an open Letter about this issue to the Ombudsman, and this report reinforces the point that prisons must have the resources to implement PPO recommendations otherwise what is the use of them in the first place?”

Prisons minister Rory Stewart said: “We are determined to install full airport-style security with the right dogs, technology, scanners and search teams to detect drugs.

“We will install the technology in Durham and we will be rolling it out across our local prisons. Tackling drugs is vital for reducing violence.”