Inspectors found:

o The unit for vulnerable detainees was an oppressive and degrading environment. There was no privacy for detainees, no policy or assessment process or evidence of care planning.

o Drugs posed a serious security issue, but there was no drugs strategy, although detoxification and treatment services had improved.

o The STHF had a restricted regime and a confused role. Despite previous inspectorate recommendations, it continued to hold women in wholly inappropriate conditions, some of them extremely distressed, or co-located with male ex-prisoners. The UK Border Agency (UKBA) needs urgently to find suitable alternative accommodation for women.

o Arrangements for the support of potentially suicidal or self-harming detainees were inadequate, with poor documentation, and some inappropriate separation of vulnerable detainees. Use of force had increased and was not always well managed.

Anne Owers, Chief Inspector of Prisons, said:

"Colnbrook manages the most challenging and vulnerable detainees in the immigration estate. The difficulties facing staff are compounded by the increasing length of stay of many detainees and the frustration that ensues. On top of this, the centre is required to hold women in the wholly inappropriate setting of its short-term holding facility.

"Overall, we found little improvement at Colnbrook since our last visit. Indeed, there was evidence of the centre taking inappropriate steps to manage some of the challenges it faces; in particular, there were examples of separation being misused and the vulnerable persons unit was not fit for purpose.

"Staff and managers readily admitted that Colnbrook was struggling to cope. It is to be hoped that the opening of new accommodation elsewhere in the estate will relieve some of the excessive pressure under which the centre now operates."


Report on a full announced inspection of Colnbrook Immigration Removal Centre, 17-21 November 2008 by HM Chief Inspector of Prisons. Report compiled, March 2009, published Tuesday 2nd June 2009 

Introduction: Colnbrook immigration removal centre (IRC), at Heathrow airport, is the most secure facility in the immigration detention estate. Run by Serco, it holds male detainees, many of whom have proved difficult to hold in less secure settings. The adjoining short-term holding facility (STHF) holds both men and women. On our previous visit, we found that Colnbrook was struggling to manage a difficult mix of detainees. On our return for this full announced inspection, we could find little evidence of improvement and the establishment remained at the outer limits of its capacity to cope.

Safety continued to be a significant concern. The population remained as challenging as ever, with an increased proportion of ex-prisoners, large numbers of detainees who had proved difficult to control elsewhere and many individuals who had been at the IRC for many months, or even years, and who were inevitably frustrated by the lack of progress of their cases. Colnbrook also housed some of the most vulnerable individuals in the immigration estate, but the vulnerable persons unit was a badly designed response and needed to be reviewed. On top of this, drugs posed a serious security issue, although detoxification and treatment services were much improved.  

We continued to have serious concerns about the STHF. It had a restricted regime and its role remained confused: it acted as both a short-term holding facility and a first night and induction unit for the long-term facility. Contrary to our previous recommendations, it continued to hold women in wholly inappropriate conditions which could not guarantee them adequate and appropriate treatment. The UK Border Agency (UKBA) needs urgently to find suitable alternative accommodation for women.

Given the nature of the population, it was disappointing that, despite some improvement, weaknesses remained in anti-bullying work. Deficiencies were also noted in the management of suicide and self-harm, with some inappropriate separation of vulnerable detainees and examples of excessive use of demeaning anti-ligature clothing. Use of force had increased and was not always well managed. The separation unit was sometimes used inappropriately as a punishment.   

Accommodation was of a good standard, but poor ventilation remained a problem. Staff generally tried hard to manage the difficult mix of detainees with patience and good humour, and a personal officer scheme was beginning to have an impact. However, staff turnover remained high and a mentoring scheme had only just been put in place. There were also weaknesses in the reward scheme and complaints were poorly managed. There was insufficient use of professional interpretation services across the centre to ensure that detainees understood what was happening to them. Faith provision was good, but there was scope to develop diversity structures further. Healthcare was generally weak. 

There was a much greater quantity of paid work than at the last inspection, although the breadth of options was limited. Education remained restricted and suffered from poor take-up by detainees. Time out of room and the range of leisure activities were reasonable. Physical education provision was good and there was an adequate library.

The welfare team provided a much appreciated service, although the staff lacked training. Access to the outside world was reasonable, with generally sound visiting arrangements and good access to telephones and the internet. Detainees were usually given sufficient warning of their date of removal to allow them to prepare appropriately, but we still came across examples where this was not the case. There was a need to clarify the role of the last night centre.

Colnbrook manages the most challenging and vulnerable detainees in the immigration estate. The difficulties facing staff are compounded by the increasing length of stay of many detainees and the frustration that ensues. On top of this, the centre is required to hold women in the wholly inappropriate setting of its short-term holding facility. Overall, we found little improvement at Colnbrook since our last visit. Indeed, there was evidence of the centre taking inappropriate steps to manage some of the challenges it faces; in particular, there were examples of separation being misused and the vulnerable persons unit was not fit for purpose. Staff and managers readily admitted that Colnbrook was struggling to cope. It is to be hoped that the opening of new accommodation elsewhere in the estate will relieve some of the excessive pressure under which the centre now operates.

Anne Owers ~ HM Chief Inspector of Prisons

Selected extracts:

HE.4 Detainees were locked up for nearly the whole of their time in the short-term holding facility (STHF), which continued to perform a range of disparate functions. It was unfit as a first night and induction unit, lacked an adequate regime and was wholly unsuitable for women.

HE.18 . . . . health services in general were a concern, with many recent policy changes yet to bed in, an over-reliance on agency staff inexperienced in IRC work, and poor medicines management. The centre had made efforts to improve access to legal advice. There was an efficient but over-stretched on-site immigration team.

1.1 . . . . arrival at the centre was reported in negative terms in our detainee survey.

1.7 Only 30% of survey respondents said that they felt safe on their first night. Perceptions were affected by early experience of the STHF, which was also used as a first night centre preceding transfer to the IRC. There were long hours of lock-up in the STHF and no formal induction. The experience could be degrading for the small number of women held in isolation alongside a male population in the STHF. The STHF received the most challenging population in the detention estate, but remained without any formal rules of governance.

2.1 . . . . For most detainees, overall living conditions were sound. This was not the case for detainees located in the vulnerable persons unit, where the accommodation was cramped. The longstanding unresolved problem of poor ventilation remained the most significant complaint raised by detainees.

3.1 Only just over half of detainees said that they had a legal representative. Detainees related access to means, and two-thirds had less than £5 in their accounts. The welfare team was not equipped to fill the gap in provision.

3.8 Detainee frustration and anxiety, even when they were cooperating with removal, was fuelled by the remoteness of UKBA case holders and the perfunctory standard of UKBA reviews of detention, which did not always correspond to published UKBA policy.   

4.1 Bullying was a significant problem and much of it was not being reported or dealt with through the formal systems. Investigations of bullying were completed to a high standard but support for victims was inadequate and little was done to address the behaviour of identified bullies. The policy on the management of detainees at risk of self-harm was not specific to the centre and the guidance was not followed by staff. Management information was insufficiently detailed and commitment to management oversight through regular and well-attended meetings was inadequate. The quality of assessment, care in detention and teamwork (ACDT) documentation was generally poor and reviews were generally not well managed. There was insufficient monitoring of detainees subject to both ACDT and Rule 40 (removal from association in the interests of security or safety). The use of anti-ligature clothing remained high and governance arrangements were weak.

4.36 The vulnerable persons unit offered no privacy and was an oppressive and degrading environment. There was no policy setting out the role and function of the unit. It provided a limited regime. The list of examples of vulnerability was diverse. None of the detainees located there at the time of the inspection had undergone an assessment and none had an individual care plan. The unit had been used to accommodate detainees with a mental health problem, which directly contravened the instructions about the process of placement. 

5.1 There had been a lot of recent policy development, but this had not been reflected in the delivery of patient care, and permanent staff did not appear to have been fully involved in the change process. The health needs assessment lacked local data and was descriptive rather than analytical. There were a number of nursing vacancies, resulting in a reliance on agency staff, and induction of agency staff was insufficient. Agency staff did not carry keys, which limited their ability to carry out nursing duties. Standards of record keeping were poor. A number of errors had occurred in medicines management and some of the practice we observed was poor. Dental provision was for emergency care only and did not reflect the needs of the current population of the centre. Primary mental health services were adequate, as were mental health services.

8.1 . . . . here was insufficient de-escalation of use of force incidents, and the monitoring of these incidents was inadequate. The use of temporary confinement under Rule 42 was correctly authorised but detainees were held on the temporary confinement unit for long periods after they had become compliant. The Rule 40 removal from association rooms were unfurnished and detainees were placed on Rule 40 several hours after the inciting incident had been resolved. Complaints were inadequately investigated. The standard of replies was poor, many were not answered within the prescribed timescale and the standard of replies was insufficiently monitored.

9.1 Food was of good quality, with plentiful portions and a variety of choices on offer each day, but there was a high level of discontent among detainees. Consultation arrangements were in place but responsiveness to detainees' requests was inconsistent. Access to the shop was good, but the range of items on offer was limited.

End of Bulletin:

Source for this Message:
HMCIP