Report on an inspection visit to police custody suites in Avon and Somerset Police

Summary

This report describes our findings following an inspection of Avon and Somerset Police custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and the Care Quality Commission (CQC) in January 2024. It is part of our programme of inspections covering every police custody suite in England and Wales.

The inspection assessed the effectiveness of custody services and outcomes for detained people throughout the different stages of detention. It examined the force’s approach to custody provision in relation to detaining people safely and respectfully, with a particular focus on children and vulnerable adults.

HM Inspector Wendy Williams oversaw this inspection until 31 March 2024, when her tenure ended. These are her conclusions about the force’s performance. At the time of publication, HMI Michelle Skeer holds responsibility for Avon & Somerset Police.

To help the force improve, we have made one recommendation to it and its police and crime commissioner. This addresses our main cause of concern.

We have also highlighted a further ten areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and working with partners

Avon and Somerset Police has clear governance arrangements for the provision of custody services. The force monitors custody services at strategic and operational meetings and senior leaders take an active interest in custody.

The force manages custody services across three suites at Patchway, Keynsham and Bridgwater. These facilities are based in relatively new buildings funded by private finance initiative contracts. The force has made sure that these buildings are well maintained.

The force has full-time personnel trained to provide custody services. Initial training is comprehensive and follows the national course developed by the College of Policing. The force regularly reviews how many personnel work in custody so it can meet demand. However, we that found detention officers weren’t always deployed in the most efficient way and couldn’t always meet the needs of detainees, such as providing showers or exercise.

There are good processes for reporting and investigating adverse incidents. The force has adopted the College of Policing’s authorised professional practice (APP) and since our last inspection has developed a standard operating procedure. But we found that custody personnel don’t always follow guidance about setting observation levels to keep detainees safe. This forms part of our cause of concern about risk management.

The force collects a range of information to manage custody performance. But some of this data is inaccurate or incomplete. This hinders the force’s ability to manage performance effectively and make improvements in some areas.

The force generally follows the Police and Criminal Evidence Act 1984 (PACE) and its codes of practice, but doesn’t always do so when completing reviews of detention. We found that custody inspectors were completing reviews far too early, to coincide with the time their shift ended rather than the time that the review was due. This practice was as a result of a force policy that focused on reducing demand on frontline inspectors. We gave the force feedback on this policy, and it was revoked during our inspection.

The governance and oversight of the use of force is better than we usually see, but some improvements are needed. Incidents are generally well recorded on custody records but not all officers complete the required use of force forms. We found there was an over-reliance on using anti-rip clothing to mitigate risks of self-harm rather than considering alternatives such as higher observation levels. We still have concerns about the levels of use of PAVA incapacitant spray, which is higher than we usually see.

The quality of recording on custody records needs to improve. We saw custody officers complete thorough risk assessments, but they didn’t always record all the information provided to them by detainees. Detention officers don’t always record cell visits in enough detail, and we found that identical text was sometimes copied and pasted from one visit to the next.

The force understands its responsibilities under the public sector equality duty. It monitors custody data relating to throughput and strip searches by gender and ethnicity to identify disproportionality. But the force’s data shows that in the last 12 months custody officers recorded the ethnicity of 1,470 detainees (7.96 percent) as unknown. This limits the force’s ability to establish fair and equal outcomes for detainees.

The force is open to external scrutiny, and independent custody visitors (ICVs) visit all suites on a weekly basis. The ICVs told us that they have a good relationship with the force.

The force and its partners have a strong commitment to keeping children out of custody. But too many children who are charged and refused bail are detained in custody overnight instead of being moved to secure or other appropriate alternative accommodation. The force doesn’t always record whether it has made a request to move these children.

The force works well with mental health services to improve the support for people with mental health conditions. We saw good evidence of people being diverted from custody where appropriate. However, the force told us that there can be lengthy delays when moving detainees who require a mental health assessment while they are in custody. This is a poor outcome for these detainees.

Pre-custody – first point of contact

Frontline officers have a good understanding of what can make a person vulnerable and consider this when deciding what action to take at incidents. They also take into account the nature and seriousness of the incident or allegation. When dealing with incidents involving children, they speak with a custody officer to discuss safeguarding and alternatives to arrest and detention.

Frontline officers said they weren’t always confident that they had all the information they needed from call handlers before attending incidents. They can use their handheld devices to access further information, but this isn’t always practical.

The force provides good support for officers dealing with incidents involving people with suspected mental health conditions. They can speak with mental health professionals using a telephone support line that operates 24 hours a day, 7 days a week. However, frontline officers often face long delays in accessing health-based places of safety for people they detain under section 136 of the Mental Health Act 1983. This is a poor outcome for those in potential crisis and an inefficient use of police resources.

In the custody suite – booking-in, individual needs and legal rights

Respect

Custody personnel are patient and reassuring and treat detainees with respect. Privacy is reasonably well maintained in most areas, and custody personnel inform detainees that there is CCTV operating in suites and cells.

Meeting individual and diverse needs

Custody personnel understand how to meet the needs of detainees from protected and minority groups and try their best to meet these needs.

There are no physical adaptations in cells, but all custody suites have reasonable facilities to meet the needs of detainees with disabilities.

The force is generally good at meeting the needs of women. But it doesn’t always ask detainees of any gender if they have caring responsibilities.

Risk assessments

The identification, management and recording of risk is not good enough. This forms part of our cause of concern.

There is no standard process to prioritise booking in children and vulnerable detainees. This is left to the discretion of individual custody officers.

Custody officers carry out initial risk assessments, but they record only basic information on custody records. The observation levels they set don’t routinely match the risks presented by detainees, and are often set too low to mitigate risk. Detention officers usually carry out checks on time, but the records of cell visits don’t always reflect the detainee’s circumstances.

Detainees who are under the influence of drink or drugs are often placed on level 1 observations instead of level 2 observations with rousing checks, where officers rouse the detainee and speak to them. This is contrary to APP. Officers who carry out level 3 constant observations do so in a busy area of the custody suite where there are distractions.

Most custody officers don’t routinely remove clothing with cords, or items such as jewellery. However, custody officers sometimes use anti-rip clothing for detainees at risk of self-harm, instead of considering whether they could manage the risk through less intrusive methods.

All custody personnel carry personal-issue anti-ligature knives, which means they can respond to potential self-harm incidents without delay. Custody personnel maintain good control of keys.

Individual rights

Arresting officers provide a clear account of the circumstances surrounding an arrest. But they don’t always explain the necessity for the arrest in enough detail, and custody officers don’t probe this.

Custody officers clearly explain legal rights and entitlements to detainees. There are easy read and Braille versions for detainees who need these, and enough copies of PACE code C books to give to detainees. Detainees are given information about how they can have their DNA samples destroyed. All detainees can speak with their legal representatives privately in person and on the telephone.

There is information in all suites informing detainees about how they can make a complaint.

In the custody cell – safeguarding and healthcare

Physical environment

The general cleanliness of all suites is good. There is good-quality CCTV in cells and corridors. However, there are potential ligature points at all three suites in the exercise yards, communal showers and cells.

The force has removed the doors to clinical rooms and replaced them with curtains. This undermines detainees’ privacy and dignity.

Custody personnel have a good understanding of emergency evacuation procedures. They have received recent fire safety training, but none have carried out a practical fire evacuation.

Detainee care

Custody personnel show a caring attitude towards detainees. The detainees we spoke to were positive about the care they had received in custody.

However, detainees aren’t always told about the provisions available to them, such as exercise and showers, so may not know what they are entitled to. Custody personnel regularly provide food and drink. And detainees going to court are offered showers, particularly at Patchway.

The force has a particularly good range of reading material. There is a good supply of replacement clothing, and mattresses, pillows and blankets for use in the cells.

Safeguarding

There are clear processes for officers to report safeguarding concerns about children and vulnerable adults. Custody personnel make early contact with the local authority emergency duty teams when children are detained in custody. A healthcare practitioner (HCP) sees all children to safeguard their welfare. The force is exploring opportunities to improve the liaison and diversion (L&D) service for children.

Custody personnel generally consider how to safeguard the welfare of children leaving custody and make sure they get home safely.

Appropriate adults

Children and vulnerable adults didn’t always receive prompt support from an appropriate adult to safeguard their welfare in custody. There is no out-of-hours appropriate adult (AA) service for children, and the overnight service for adults is limited.

Information about AA contact and arrival times is often missing or unclear on custody records. The force doesn’t review this data to assess how well this service is operating.

Children

The force is proactive in keeping children out of custody wherever possible, and custody officers are confident in refusing detention. From our case reviews we were satisfied that where children were detained in custody it was necessary and justified.

There are no procedures to prioritise the booking in of children. Girls under 18 aren’t always allocated a female member of staff to look after their welfare needs.

When children are detained in custody it is often for lengthy periods. The force monitors this and has some understanding of the reasons for it.

Health care – governance

Experienced and competent HCPs are allocated to each custody suite and provide healthcare cover 24 hours a day, 7 days a week. Partnership working between the force and partners is good, and they have addressed recent staff shortages. Most detainees receive prompt clinical assessment. However, there are no lockable doors in the medical rooms, which means that the detainees’ dignity and confidentiality aren’t protected.

Mental health

The L&D service provided by Advice and Support in Custody and Court (ASCC) operates in all suites and supports vulnerable detainees, children and young people in custody and after they are released.

The force does not use custody as a place of safety under section 136 of the Mental Health Act 1983, but it sometimes uses this power to move detainees who need a mental health assessment while in custody.

The force is proactive in identifying, supporting and managing people with mental health concerns in custody and in the community. The force is ambitious and committed to continuous improvement and innovation in this area.

All suites have good support for detainees with substance misuse needs, and a community referral process. Robust arrangements are in place to manage medicines. Detainees going to court can take their own medicines with them. But the force should provide a way of transferring medicines that have been given to detainees while in custody to court.

Release and transfer from custody

The force cannot assure itself that it is safely managing risk when detainees are released from custody. This forms part of our cause of concern.

Custody officers generally carry out pre-release risk assessments when the detainee is present. But this doesn’t always happen when detainees are released to court. The assessments that are carried out aren’t recorded in enough detail, and often lack important information.

Some custody officers we spoke to weren’t aware of the enhanced safeguarding arrangements for those arrested on suspicion of committing serious sexual offences, or their responsibilities to make sure that the correct procedures are followed.

Detention officers manage the pre-release process, risk assessment and handovers when detainees are released to court. Custody officers don’t provide any oversight and don’t supervise the handovers.

When detainees are remanded, they are transferred to the next available court by the force’s external contractor, or by police officers if outside regular hours. This minimises the time that detainees spend in custody.

Cause of concern and recommendation

Introduction

This report is one in a series of inspections of police custody carried out jointly by HMICFRS and CQC. These inspections are part of the joint work programme of the criminal justice inspectorates and contribute to the UK’s response to its international obligations under the United Nations Optional Protocol to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).

The national rolling programme of police custody inspections, which began in 2008, makes sure that custody facilities in all 43 forces in England and Wales are inspected regularly.

OPCAT requires that all places of detention are visited regularly by independent bodies – known as the National Preventive Mechanism (NPM) – which monitor the treatment of, and conditions for, detainees. HMICFRS and CQC are two of several bodies making up the NPM in the UK.

Our inspections assess how well each police force fulfils its responsibilities when detaining people in police custody, and the outcomes for them. This includes how safely they are managed and how respectfully they are treated.

Our assessments are made against the criteria set out in our ‘Expectations for police custody’. These standards are underpinned by international human rights standards and are developed by the two inspectorates. We consult other expert bodies on them across the sector and they are regularly reviewed. This helps to achieve best custodial practice and promote improvements.

The expectations are grouped under five inspection areas:

• leadership, accountability and working with partners;
• pre-custody – first point of contact;
• in the custody suite – booking-in, individual needs and legal rights;
• in the custody cell – safeguarding and healthcare; and
• release and transfer from custody.

The inspections also assess compliance with the PACE 1984, its codes of practice and the College of Policing’s authorised professional practice for detention and custody.

The methodology for carrying out the inspections is based on:

• a review of a force’s strategies, policies and procedures;
• an analysis of force data;
• interviews and focus groups with personnel;
• observations in suites, including discussions with detainees; and
• an examination of case records.

We also analyse a representative sample of custody records from all suites in the force area for the week before the inspection starts. For Avon and Somerset Police, we analysed a sample of 100 records. The methodology for our inspection is set out in full at Appendix I.

Terminology in this report

Our report contains references to ‘national’ bodies, strategies, policies, systems, responsibilities, processes and data. In some instances, ‘national’ means applying to England and Wales. In others, it means applying to England and Wales and Scotland, or the whole of the United Kingdom.

Section 1. Leadership, accountability and working with partners

Expected outcomes: Leadership, accountability and working with partners

Chief officers have a clear priority to protect the safety and well-being of detainees and to divert vulnerable people away from custody.

Leadership

Avon and Somerset Police has clear governance arrangements for the provision of custody services.

An assistant chief constable has overall responsibility for custody, with a chief superintendent and superintendent within the wider criminal justice portfolio serving as the force leads for custody. A chief inspector is responsible for the daily management of custody services.

The force monitors custody performance at several strategic and operational meetings.

A new multi-agency custody assurance board meets quarterly, chaired by the chief superintendent. Agencies represented on the board include Avon and Somerset Police, British Transport Police, the NHS, immigration services and the Office of the Police and Crime Commissioner. The board looks at what is working well, where the force needs to improve, and how custody services affect other teams.

The custody assurance board reports into a wider force performance meeting chaired by the assistant chief constable, and into the Office of the Police and Crime Commissioner.

The criminal justice chief superintendent chairs three leadership meetings every month that focus on performance, people and planning. This forum has oversight of custody performance.

The custody chief inspector chairs a weekly meeting with custody inspectors that focuses on operational issues such as resourcing, equipment, problem-solving, the relationship with partners and training requirements.

Custody inspectors attend force-wide meetings on the thematic areas they lead. This includes the force safety group, mental health forums and meetings focusing on children and young people.

The force manages custody services across three suites at Patchway, Keynsham and Bridgwater. These facilities are based in relatively new buildings funded by private finance initiative contracts. The force has made sure that these buildings are well maintained.

During our inspection we gave the force a report on the physical conditions of the buildings, in particular the potential ligature points we found at all three suites, which present a risk to detainees. It immediately started to address some of the concerns we raised.

The force has a number of full-time personnel trained to provide custody services. It has ten inspectors, including a development post, 60 custody officers and 90 detention officers. The force told us it recently faced the challenge of having insufficient staff to meet demand and operate safely. As a result, some suites had to be closed at times. At the time of our inspection the force had additional staff to improve resilience while it carried out a full review of its custody resources and the wider demand.

During our inspection there were usually enough staff working on each shift. But the detention officers are allocated specific roles, which isn’t always the most effective way of deploying them. They were sometimes stretched when the suites were busy, and couldn’t consistently meet detainees’ needs, such as providing showers and exercise. Custody officers spend a lot of time chasing investigating officers for case updates, which isn’t an effective use of their time.

Initial training for custody personnel is comprehensive and follows the national course developed by the College of Policing. Before carrying out their duties independently, all personnel spend time shadowing more experienced colleagues and complete a workplace assessment. The force provides five training days a year to all custody personnel for their continuing professional development.

The force has good processes for reporting and investigating adverse incidents that happen in custody. Personnel understand what they need to do when dealing with these situations. The force reviews incidents at a scrutiny board and shares the learning from this with all personnel at meetings and in weekly emails. There have been no deaths in custody since our last inspection.

The force has adopted the College of Policing’s APP for custody, and since our last inspection has developed a standard operating procedure. However, we found that custody personnel don’t always follow guidance in relation to setting observation levels to keep detainees safe. This forms part of our cause of concern about the management of risk.

Accountability

The force collects a range of information to manage custody performance, including:

• the number of detainees entering custody;
• waiting times;
• average detention lengths;
• strip search data; and
• the number of children detained.

Not all of this data is accurate, which hinders the force’s ability to manage performance effectively and make improvements in some areas. For example, when force or restraint is used during an arrest, custody officers sometimes incorrectly record that the incident took place in custody. And Avon and Somerset Police doesn’t accurately identify and record all detainee ethnicity information.

Furthermore, some data is incomplete. For example, custody records don’t always show the time that AAs are called and arrive, so there is no record of how long children and vulnerable adults wait for support from an AA.

We also found that where children who had been charged and refused bail were eligible to be moved to local authority accommodation, the force only recorded requests being made in 42 out of 61 cases, and couldn’t account for the other 19 cases.

The force monitors data at operational meetings, but until recently there was limited oversight at chief officer level. The force set up the custody assurance board to address this gap.

The force generally follows PACE and its codes of practice but doesn’t always do so when completing reviews of detention. Reviews often don’t comply with what is required by paragraphs 15.1–15.14 of PACE code C. For example, we found that reviews rarely happened on time. In many cases custody inspectors carried them out far too early, to coincide with the time their shifts finished rather than when the reviews were due. This was often in the early hours of the morning when detainees were asleep. This practice was a result of a force policy that focused on reducing demand on frontline inspectors. We gave the force feedback on this policy, and it was revoked during our inspection.

Almost half of the first reviews we saw in our custody record analysis were carried out while the detainee was asleep. Custody personnel didn’t always inform detainees at the earliest opportunity that a review had taken place and their further detention had been authorised.

The governance and oversight of the use of force are better than we usually see, but some improvements are needed. Incidents are generally well recorded on custody records, and we saw some detailed entries. However, not all officers complete the required use of force forms, and we only received half the number we expected in our case reviews.

In the cases we reviewed, custody officers and detention officers were good at de-escalating incidents. However, we found there was an over-reliance on using anti-rip clothing to mitigate risks of self-harm rather than considering alternatives such as higher observation levels. This meant that force was sometimes used to remove clothing when it could have been avoided. Custody officers didn’t always provide a rationale for using anti-rip clothing to manage detainee risk.

An inspector reviews use of force incidents and we saw evidence that CCTV is also reviewed. Senior managers can easily access custody CCTV if needed.

Since our last inspection, the number of incidents involving PAVA incapacitant spray in custody has reduced, but it is still higher than we usually see. We still have some concerns regarding the use of PAVA spray in the confined space of cells and cell corridors.

We reviewed 34 use of force incidents and identified learning for Avon and Somerset Police in two of them. We referred these two cases back to the force to review itself.

The quality of recording on custody records needs to improve. The force has quality assurance and review processes in place, but these haven’t picked up some of the concerns we identified. We saw some detailed entries on detention logs, but overall, recording isn’t good enough and doesn’t reflect the good practices we observed in the suites.

For example, we saw custody officers complete thorough risk assessments, but they didn’t always record all the information provided to them by detainees. They relied on the drop-down menus and templates on the custody computer system. These templates provide text prompts for personnel to use when filling out specific parts of the custody record. But we found that custody officers were using these templates as their final record instead of adding additional text or deleting the parts that didn’t apply. This led to confusing and contradictory entries on custody records.

Detention officers don’t always record cell visits in enough detail. We found evidence of identical text used from one visit to the next, and some entries merely stated AIO to mean ‘all in order’. This is poor practice.

The force understands its responsibilities under the public sector equality duty. It monitors custody data relating to throughput and strip search by gender and ethnicity to identify disproportionality. But force data shows that in the last 12 months custody officers recorded the ethnicity of 1,470 detainees (7.96 percent) as unknown. This limits the force’s ability to establish fair and equal outcomes for detainees.

Custody personnel have received training on the Equality Act 2010 and on topics such as how to approach detainees with mental health conditions or detainees who are neurodivergent.

The force is open to external scrutiny, and ICVs visit all suites on a weekly basis. ICVs told us they have a good relationship with the force. They can raise concerns they identify during their visits directly with custody personnel, who deal with these at the time where possible. The ICV scheme manager can also raise concerns when they attend regular custody meetings, and they have access to performance information.

Working with partners

The force and its partners are strongly committed to keeping children out of custody. Custody officers are robust in refusing detention when appropriate and we saw some good examples of this happening. The force monitors the numbers of children coming into custody and works with the youth justice service to support children and address the causes of their offending behaviour.

However, too many children who are charged and refused bail are detained in custody overnight instead of being moved to secure or other appropriate alternative accommodation. In the year up to our inspection, the force made 42 requests for local authority accommodation but only one child was moved. The force doesn’t record whether a request has been made in all cases, so can’t monitor this effectively. The force and its partners need to do more to improve outcomes for these children.

The force works well with mental health services to improve the support for people with mental health conditions. It has good joint working arrangements, and we saw good evidence of diversion from custody. However, the force told us that there can be lengthy delays when moving detainees who require a mental health assessment while they are in custody. This is a poor outcome for these detainees.

The force sometimes uses section 136 of the Mental Health Act 1983 to move these detainees to a health-based place of safety. But it needs to work better with partners to understand the data and reduce delays in moving detainees. This is to make sure that those with mental health conditions aren’t held in custody for longer than necessary while waiting to move to a health-based setting.

Section 2. Pre-custody – first point of contact

Expected outcomes: Pre-custody – first point of contact

Police officers and staff actively consider alternatives to custody. They effectively identify vulnerabilities that may increase individuals’ risk of harm. They divert children and vulnerable adults away from custody when detention may not be appropriate.

Assessment and diversion at first point of contact

Frontline officers have a good understanding of what can make a person vulnerable. They told us that they consider this when deciding what action to take at incidents. They also take into account the nature and seriousness of the incident or allegation.

They told us that many of the children they dealt with were suspected of being involved in serious offences, and that arrest was appropriate in these cases. It is the force’s policy that when officers attend incidents involving children, they speak with a custody officer to discuss safeguarding and alternatives to arrest and detention. Frontline officers said they felt custody officers sometimes sought to refuse detention remotely rather than give their view on opportunities to divert children from custody.

The force operates a detainee transport service on Friday and Saturday nights to transfer compliant detainees to custody. This service aims to reduce demand on frontline officers, so they have more time to attend incidents instead of spending time travelling long distances to custody suites. Arresting officers provide details of the arrest so that the detainee transport service staff have enough information to book detainees into custody.

Frontline officers told us that they weren’t always confident they had all the information they needed from call handlers before attending incidents. They said that some relevant information is often missing, although they acknowledged that not all information is available from initial calls. All frontline officers have handheld devices and they can use these to look up further information before attending incidents. However, this isn’t always practical when officers are responding to emergency calls, or if they are working alone.

The force provides good support for officers dealing with incidents involving people with suspected mental health conditions. When deciding whether to detain a person under section 136 of the Mental Health Act 1983, officers can speak with mental health professionals using a telephone support line that operates 27 hours a day, 7 days a week in the force control room. There is also a triage car operated by mental health professionals that can attend incidents. Officers told us that this was a valuable resource, but during busy periods it wasn’t always available when needed.

Frontline officers understand that custody shouldn’t be used as place of safety for people detained under section 136 of the Mental Health Act 1983. They couldn’t recall this ever happening in the force. However, they often have difficulties in accessing local health-based places of safety. This can be due to limited availability, or because of the need for people detained under section 136 to attend hospital first for physical health checks.

As a result, officers regularly attend hospital accident and emergency departments with individuals in potential mental health crisis. Once at accident and emergency, they can spend a long time waiting in public areas for individuals to be assessed, often for their entire shift. This is a poor outcome for those in potential crisis and an inefficient use of police resources.

Section 3. In the custody suite – booking-in, individual needs and legal rights

Expected outcomes: In the custody suite – booking-in, individual needs and legal rights

Detainees are treated respectfully in the custody suite and their individual needs are identified and met. Detainees’ risks are identified at the earliest opportunity and managed effectively. Detention is appropriately authorised. Detainees are informed of their legal rights and can freely exercise these rights while in custody.

Respect

Custody personnel are patient and reassuring and treat detainees with respect.

Privacy is reasonably well maintained and there are barriers between the booking-in desks in all suites. There is a private booking-in room in each suite that can be used for booking in vulnerable detainees or for having sensitive conversations. We saw custody officers using these facilities, although they didn’t always record this on the custody record.

CCTV operates in all suites, including in the cells. There are posters in the main areas of the suites advising detainees of this. Custody personnel also inform detainees that there is CCTV in the cells, but that the toilet area is obscured from view.

The shower doors in all suites are too low and there is a cell directly opposite each shower. Custody personnel told us they don’t allow anyone to walk in the corridor while detainees are using the shower and they make sure the hatch of the opposite cell is closed. However, in our view the shower areas don’t offer enough privacy.

We saw that detainees wear appropriate clothes and footwear when walking around suites or when they attend interviews. But when force is used to remove clothing from detainees at risk of self-harm, this isn’t always managed well enough to protect their dignity. They are provided with replacement clothing, but they don’t always put this on. Officers don’t always pay attention to whether detainees dress themselves, and some remain naked in their cells. This is especially the case with detainees who are intoxicated.

Meeting diverse and individual needs

Custody personnel understand how to meet the needs of detainees from protected or minority groups and try their best to meet these needs.

There are no physical adaptations in cells such as higher benches or call bells at a different height. However, there are reasonable facilities in all custody suites to meet the needs of detainees with disabilities:

• all suites have wheelchairs in good condition;
• some extra thick mattresses are available, and these are in good condition;
• there are no sight lines (markings on the cell walls to help visually impaired detainees navigate the confined space), but two of the walls in each cell are painted in different colours;
• all suites have rights and entitlements available in Braille and easy read versions;
• all suites have hearing loops, to help detainees with hearing devices hear conversations more easily;
• there is an adapted shower and toilet in all suites.

Custody personnel have a reasonable knowledge of neurodiversity and how this can affect detainees. They told us that the force had provided training, although this wasn’t recent. The suites are well equipped to support the needs of neurodiverse detainees, including different coloured walls in the cells. Detainees who need help with reading can access coloured page overlays that the force provides.

Each suite has four cells for vulnerable detainees. These cells have a large glass pane in the door that can be left uncovered for detainees who have claustrophobia.

Custody personnel we spoke to were aware of issues around the treatment of transgender detainees, but they couldn’t remember the force providing any specific training on this topic.

Each suite has a good range of religious items to allow detainees to observe their faith. These cover most of the major religions except Hinduism. Qurans are stored above head height, although they were not all wrapped as they should be.

During the booking-in process, custody officers ask female detainees if they would like to speak with a female member of staff in private, and they are allocated a female point of contact if needed. We saw this happening, but it wasn’t always recorded on the custody record. Female detainees are offered feminine hygiene products, and there is a good supply in all suites.

Custody officers don’t always ask detainees of any gender if they have caring responsibilities.

The force provides interpreters for detainees who speak little or no English through a translation and interpreting agency, DA Languages. Detainees can use a two-way handheld phone at the booking-in desk to speak with interpreters.

Risk assessments

The identification, management and recording of risk isn’t good enough. Some working practices don’t follow APP, which means the force isn’t able to consistently make sure that detainees in custody are safe. This forms part of our cause of concern.

Detainees are generally booked into custody quickly, although they may have to wait in holding cells if the suite is busy when they arrive.

When there are queues, some custody officers assess risk to prioritise booking in children and vulnerable detainees. But there is no standard process for this, and it is down to the discretion of individual custody officers.

We saw an example of good practice during our inspection, when a custody officer went to the holding cells and prioritised booking in a young person. They were accompanied by a detention officer who offered food and drink to other detainees and officers waiting to enter the custody suite.

Custody officers carry out initial risk assessments, but they record only basic information on custody records. From our observations in suites, we saw that custody officers communicated well with detainees and explained the purpose of the risk assessment. They often asked probing questions when a detainee’s answers highlighted risk, and considered other sources of information such as the Police National Computer and Niche. But the recording of these assessments is poor and records showed little evidence of risk assessments being carried out to the same good standards we observed.

Custody officers don’t always set observation levels that match the risks presented by detainees. In many cases the observation level was set too low to mitigate the risk and there was insufficient justification for the decision.

When detainees are under the influence of drink or drugs, custody officers often place them on level 1 observations instead of level 2 observations with rousing checks. This is contrary to APP guidance.

We found that risk management often operated between two extremes. We found cases where detainees at risk of self-harm were placed on level 1 observations with checks every 60 minutes, and no other measures to keep them safe. But for other detainees at risk of self-harm, custody officers used anti-rip clothing instead of considering whether they could manage the risk through less intrusive methods, such as placing the detainee on a higher observation level.

When force was used to remove detainees’ own clothing, this potentially added to the risk. In these cases, custody officers needed to consider the most appropriate measures that matched the detainees’ individual risks.

Detention officers carry out checks on time, and generally the same officer provides continuity of care. However, when making a record of their visits they often use the pre-populated text prompts rather than making a specific entry on the custody record about each detainee. There is often little detail about their communication with detainees.

When custody officers identify a heightened level of risk, they can place detainees on level 3 constant observations on CCTV, or level 4 close-proximity observations. When police officers are allocated to level 3 or 4 observations, custody officers provide oral and written briefings explaining what to do, what the risks are and the need to keep a log. Officers carrying out level 3 observations do so at a central control station in the custody suite. This area is busy with other custody personnel and there are potentially a lot of distractions.

We saw that most custody officers don’t routinely remove clothing with cords, or items such as jewellery. They justify this through individual risk assessments. This is positive. However, all detainees must leave their footwear in lockers outside their cells. When clothing or footwear is removed for evidential purposes, or if a detainee needs a change of clothing, custody personnel provide suitable replacements.

Handovers between shifts are good, with a thorough focus on risk, detainee welfare and case progression. They take place in the discrete booking-in room and are recorded on CCTV. All custody personnel except HCPs attend. The outgoing custody officer presents an oral and written briefing to the incoming team. After each handover, custody officers visit all detainees in their care and take time to speak with them. However, they don’t always record this in enough detail on custody records.

Custody officers wear personal protective equipment, including PAVA spray and body-worn video. All custody personnel we spoke to had a personal-issue anti-ligature knife which they carried while on duty. This means they can respond to potential self-harm incidents without delay. Police officers carrying out level 3 or 4 observations are provided with an anti-ligature knife and cell keys.

Cell call bells are audible and are monitored and responded to promptly by custody personnel. They can mute call bells for a maximum of ten minutes if authorised by a custody officer. Detention officers continuously monitor detainees on CCTV while call bells aren’t in operation.

Custody personnel maintain good control of keys. They use a unique passcode to access keys from secure tracker cabinets and then to return them at the end of their shift. This records who has the keys and for how long.

Individual legal rights – detention

Arresting officers provide a clear account of the circumstances surrounding an arrest. But they don’t always explain the necessity for the arrest in as much detail as is required by PACE code G 2012. And custody officers don’t always ask follow-up questions about why the arrest was necessary before deciding whether to authorise detention.

The force uses voluntary attendance as an alternative to taking a person into custody, and there are sufficient interview rooms outside custody for voluntary attendees. There is a dedicated team to support this process in some areas of the force, but not in Bristol and Bath. The force told us this can lead to inconsistent practices, particularly when completing risk assessments and carrying out fingerprinting and DNA processes.

However, Avon and Somerset Police data shows that in the past year the use of voluntary attendance has declined and the number of arrests has gone up. While the force understands why arrests have increased and is monitoring this, it isn’t able to assure itself that officers always consider alternatives to custody for vulnerable detainees.

Custody officers appropriately authorise bail and clearly explain conditions to detainees. These conditions are necessary and proportionate to the offences being investigated. When detainees are released under investigation, custody officers clearly explain the possible offences of contacting victims or witnesses while the investigation is ongoing.

The investigation teams based in custody mostly deal with cases expeditiously. Every effort is made to complete the investigation during the first period of detention. However, in other cases, custody officers sometimes spend a lot of time chasing investigating officers for updates.

When the detainee transport service books a detainee into custody, it is the force’s policy that investigating officers must attend custody promptly or make other arrangements. When this doesn’t happen quickly enough, it can result in delays in detention time and detainees can spend longer than necessary in custody.

Individual legal rights – detainees’ rights and entitlements

Custody officers clearly explain legal rights and entitlements to detainees and provide a written notice setting these out. All suites have copies of the easy read and Braille versions of the rights and entitlements.

All suites have sufficient copies of PACE code C books, and custody officers routinely offer these to detainees during the booking-in process.

When a detainee waives their right to free and independent legal advice, custody officers don’t always explore the reasons why. This is contrary to paragraph 6.5 of PACE code C 2023.

Legal representatives attend custody in person. They receive front sheets of their client’s custody record and can ask to view the whole record. All suites have enough interview and consultation rooms so that detainees can speak with their legal representatives in private. They can also speak with legal representatives privately on the telephone.

The force has developed a custody tracker system that enables legal representatives to view the front sheets of custody records remotely. They can also look for updates after detainees have been bailed. This provides an efficient way for legal representatives to access information about detainees.

All suites have posters in different languages that notify detainees of their right to free legal advice.

All custody officers we spoke to were aware of the requirements of annex M of PACE code C 2023, which states that detainees should receive documents and records about custody processes in a language they understand. During our inspection we saw custody officers providing rights and entitlements in foreign languages. We saw them contacting embassies when foreign national detainees requested this. Some countries have an agreement that their embassy will be automatically notified if one of their citizens has been detained without the detainee making a request.

When detainees are held incommunicado, this is appropriately authorised. It is generally removed when no longer required, and then the detainee can speak to the person they have requested. However, in our custody record analysis we found a case where there was no record that the detainee had been informed of this right being reinstated.

DNA samples are regularly collected from suites. However, the force doesn’t store samples securely in locked freezers or lockable rooms. This could affect the integrity of the samples. We saw posters in all the suites explaining the Protection of Freedoms Act 2012 and how DNA samples are retained and destroyed. We saw custody officers explaining this process to detainees when booking them in.

Reviews of detention

Reviews of detention don’t always comply with the requirements of PACE code C 2023. They aren’t always carried out well enough, or in the best interests of the detainee.

We found that some reviews were carried out far too early. In one case an inspector carried out a first review just 58 minutes into a detainee’s detention time. At the time of our inspection the force had a policy in place that sanctioned bringing forward PACE reviews to reduce demand on frontline inspectors. Custody inspectors carried out reviews before they finished their shift, even if this meant the review happened far too early.

We provided feedback to the force during our inspection and the policy was revoked. After this we saw some improvements in the timeliness of reviews.

More reviews than we would expect listed the detainee as being asleep, sometimes outside recognised rest periods. In our custody record analysis, 49 out of the 100 records we looked at showed sleeping reviews. In these cases, detainees were denied the right to hear the review in person, and for them or their legal representative to make representations about why they should be released.

Custody personnel didn’t routinely inform detainees about reviews carried out while they were asleep, or that a decision had been made to authorise their continued detention. This is contrary to paragraph 15.7 of PACE code C 2023. Instead, we saw inspectors informing detainees about this at the subsequent review.

Some custody records indicated that the detainee was asleep during the review, but entries either side made by other custody personnel suggested that the detainee was awake at around the same time.

Inspectors don’t always give enough consideration to doing reviews in person for children or document their rationale for not doing so.

Some inspectors rely on the standard templates of pre-populated text when completing the record of their reviews on the custody record. As a result, these entries are often unclear and contradictory and aren’t specific to the detainee’s circumstances.

We saw some reviews being done well by inspectors in person, and remotely via live CCTV link. In these cases, inspectors provided good explanations about the progress of investigations. They asked questions about the detainee’s welfare and offered washing facilities, exercise and reading materials. Their custody record entries were clear and relevant to each detainee.

We saw one example where a superintendent authorised continued detention under section 42 of PACE 1984. The record of the review was detailed, and covered the investigation, detainee welfare and the rationale for authorising continued detention.

Complaints

All suites display notices in the booking-in areas to provide detainees with information about how they can make a complaint. This information is also on the rights and entitlements leaflet provided to detainees at the time of booking in. We saw custody personnel placing leaflets about the complaints process in detainees’ property when they left custody.

There are supplies of Independent Office for Police Conduct leaflets in all custody suites. Custody personnel or inspectors offer these to detainees if they wish to make a complaint.

Custody personnel have a responsibility to inform the custody officer if a detainee makes a complaint. The custody officer must then inform an inspector. Staff are aware that they need to take forward any complaints detainees wish to make while in custody, although we saw no examples of this during our inspection.

Section 4. In the custody cell – safeguarding and healthcare

Expected outcomes: In the custody cell – safeguarding and healthcare

Detainees are held in a safe and clean environment, which protects their safety during custody. If force is used on a detainee this is as a last resort. Their care needs are met, and children and vulnerable adults are protected from harm. They have their physical and mental health, and any substance misuse, needs met.

Physical environment

Avon and Somerset Police has three designated custody suites. These are based at Bridgwater, Keynsham and Patchway.

There are potential ligature points at all three suites, including in the exercise yards and communal showers. There are also potential ligature points in cells due to the design of the toilets and some of the intercom plates. During the inspection we gave the force a comprehensive report that detailed these findings and our overall assessment of the physical conditions in all suites.

The general cleanliness of all suites is good and dedicated staff are available daily to clean cells and other areas.

All cells have toilets and sinks for handwashing and signs advising detainees that the water isn’t suitable for drinking. There are no adaptations in any of the cells, such as raised benches or call bells at a different height for detainees with physical disabilities.

Showers are generally clean and well maintained, but don’t offer enough privacy. We didn’t find any graffiti in cells, although there was some minor graffiti on the door to the exercise yard at Patchway.

The force has removed the doors to clinical rooms and replaced them with curtains. This undermines detainees’ privacy and dignity and is contrary to guidance from the Faculty of Forensic & Legal Medicine which states that clinical rooms must be locked when not in use.

In all three suites we found storerooms and kitchens that weren’t securely locked.

Detention officers carry out health and safety checks daily and make records of these. However, they don’t complete all weekly, monthly and quarterly checks. This is contrary to APP guidance. Custody personnel told us that when repairs are needed, they are usually completed quickly.

There are discrete booking-in rooms in all three suites, and each suite has four glass-fronted cells. These facilities are generally used for children and vulnerable adults. The holding areas for detainees waiting to enter custody are separate from the booking-in areas.

There is good-quality CCTV operating in the cells and corridors at all suites. However, we found that some cameras in the search rooms weren’t recording, and the force was unaware of this.

Signs pointing out the CCTV are displayed in prominent places in all suites. During our inspection we informed the force that there were no signs indicating that CCTV was operating outside the visitor rooms. The force immediately rectified this.

The CCTV monitors in all suites are positioned so that they can’t be viewed by detainees or others in the custody area on the other side of the booking-in desks.

Custody personnel have a good understanding of emergency evacuation procedures. The force has provided recent fire safety training, but no custody personnel have had the opportunity to carry out a practical fire evacuation. The fire evacuation kits at Patchway and Bridgwater are readily accessible and sufficiently stocked. At Keynsham, the handcuffs for transporting detainees in the event of an evacuation were locked away in the inspector’s office and so not readily available.

Use of force

When force is used, it isn’t always managed well.

We reviewed 34 custody records of cases where force was used, and we also viewed the CCTV footage of 20 of these cases.

In some cases where force was used, it was not proportionate to the risks assessed by custody officers or presented by the detainee. We had concerns about two cases where the use of force could have resulted in injury to officers and detainees, and we referred these to Avon and Somerset Police to review as a learning opportunity.

We saw cases where there was effective communication and negotiation by custody officers. They were patient with violent and volatile detainees in their attempts to de-escalate situations.

There were also good examples of custody officers supervising incidents effectively. They provided clear instruction and demonstrated techniques to help less experienced officers. However, we found other cases where custody officers became involved in the use of force rather than supervising and managing incidents.

When using force, officers minimised the risk of injury to detainees by protecting their heads and placing mattresses on the floor. But there were a few incidents where techniques weren’t applied correctly. As a result, one detainee nearly escaped from a cell, which resulted in further use of force and risked injury to officers and the detainee.

The use of PAVA spray in the confined space of cells and cell corridors is higher than we usually see. However, when it is used, custody personnel provide good aftercare for detainees.

We saw examples of custody officers and detention officers making detailed records of use of force incidents on the custody record. This included the rationale for their individual decisions.

However, custody officers don’t record information about detainees arriving in custody in handcuffs, including the reasons why handcuffs were used and the time they were removed. In some cases, handcuffs weren’t removed quickly enough from compliant detainees. They remained handcuffed until the custody officer authorised their detention, or during the initial search.

When force or restraint was used to remove clothing, incidents weren’t always managed well. Custody officers didn’t always justify removing the clothing or explain why it was necessary to use force.

We found cases where clothing was removed from detainees at risk of self-harm, and they were left with a mix of anti-rip clothing and either their own clothing or other replacement clothing. Some detainees then attempted to use this clothing to harm themselves, which resulted in further force being used to remove it from them. Had the incidents been properly managed from the start, or alternative methods considered to keep the detainee safe, then the use of force could have been avoided.

When force is used to remove clothing, detainees are given replacements, but they don’t always get dressed. Custody personnel don’t always pay attention to whether detainees dress themselves, and some remain naked in their cells. This is especially the case with detainees who are under the influence of alcohol.

When clothing was removed, this was often carried out in cells, and it wasn’t clear if the CCTV was switched off or covered up to maintain the detainee’s dignity. CCTV can be openly viewed by personnel working in the custody suite and by the custody personnel and superintendents who have permission to access CCTV remotely.

In some cases, female officers were present or involved when male detainees had their clothing removed in cells.

The force doesn’t routinely monitor the justification and necessity for strip searches under section 54 of PACE 1984. In one case we looked at, the strip search of a child was authorised by a custody officer instead of an inspector as required by PACE.

Officers who use force on detainees in custody don’t always submit individual use of force forms as required by National Police Chiefs Council guidance. There are no notices in the suites to remind officers to do so. We asked for use of force forms for the incidents we reviewed, but only half of the officers we expected to submit forms had done so.

Avon and Somerset Police carries out some quality assurance on the use of force in custody. It runs a quarterly scrutiny panel to review randomly selected incidents. The panel includes a custody inspector who is responsible for reviewing all the adverse incidents referred to them by custody personnel.

Not all custody and detention officers are up to date with their officer safety training. The force told us that it has plans to rectify this.

Detainee care

Custody personnel show a caring attitude towards detainees. Detainees we spoke to were positive about the care they had received in custody.

When booking in detainees, custody officers don’t always tell them about available provision such as exercise, showers and reading material, so detainees may not know what they are entitled to. However, in our custody record analysis we found that custody personnel offered showers to detainees who were going directly to court. This was particularly the case at Patchway.

The force provides a good range of food and drink and caters for all reasonable dietary requirements. Kitchen areas are generally clean, but some microwaves needed cleaning. Detention officers regularly offer food and drink to detainees.

There are stocks of distraction materials, such as fidget toys, ear defenders and stress balls, in all suites. But we didn’t see these being offered to everyone who might need them.

The range of reading material is particularly good. All suites have an extensive supply of books and magazines, including foreign language titles. We saw custody personnel offering reading materials and some detainees were reading in their cells.

Toilet paper is kept in dispensers on each corridor in the suites and is not readily available in cells. Detainees must instead ask for this, which in our view reduces their dignity.

All suites have exercise yards that are accessible via step-free routes, and a football is available for detainees to use. None of the exercise yards provide cover for bad weather. We saw detainees using the exercise yards during our inspection.

There is a good supply of replacement clothing, including socks, underwear and footwear in all sizes for detainees who need it.

The quality, condition and cleanliness of the mattresses is generally good, but some of the thin mattresses provide little support. Pillows are provided to detainees as standard, and all suites have some extra-thick mattresses if these are required.

Custody personnel give detainees two blankets on entry to the cells, and there is an adequate supply of extra blankets to hand out to those who ask for them.

Safeguarding children and vulnerable people

In the year up to our inspection, the force has worked to improve the awareness and recognition of children’s vulnerabilities across its workforce. It has provided training on child safeguarding and the voice of the child, and is planning further sessions on topics such as trauma-informed approaches.

It has clear processes for officers to report safeguarding concerns about children or vulnerable adults that they identify during arrests and investigations or in custody. Officers complete a formal risk assessment, which alerts the force’s safeguarding team so they can assess what further action to take.

In the cases we reviewed involving detained children, we didn’t find any examples of safeguarding referrals. However, we did find that custody personnel followed force policy and routinely made early contact with the local authority emergency duty teams.

It is the force’s policy that children are booked into custody in the discrete booking-in areas. During our case audits we found little evidence of custody officers using these facilities, but we did see this happening during our observations in suites. They used the main booking-in areas if no other detainees were present. However, the lack of recording makes it difficult to assess whether the force is consistently using these booking-in areas for children.

Every child detained in custody by Avon and Somerset Police should see an HCP to safeguard their welfare, regardless of medical needs. There were challenges with a recent shortage of HCPs, but the situation has improved, and the force assured us that all children now see an HCP.

The L&D service should assess the needs of every detained child and consider appropriate community support referrals. The force told us that the L&D service for children was limited, and it was exploring opportunities with partners to make improvements.

Custody personnel generally consider how to safeguard the welfare of children leaving custody. In the records we reviewed where children were released to a home address, custody officers made a record on the pre-release risk assessments about how the child was getting home. This was usually in the care of police officers or other professionals, such as care home staff.

Appropriate adults

The force’s policy requires custody officers to make arrangements for AAs to attend custody at the earliest opportunity. But we found there were delays in making these requests for AAs, and delays in them attending. This has not improved since our last inspection.

In some cases we reviewed involving children, AAs accompanied them to custody and so were available to provide early support. However, in one case the AA was contacted in the evening, but they didn’t attend custody until later the following day, just before the interview. By this time, the detainee had been in custody for 18 hours.

We found several examples involving vulnerable adults where custody officers did not make sure that AAs were available, despite the apparent risks to the detainees.

When family or friends are unavailable or unsuitable to act as an AA, the force has alternative arrangements in place.

For vulnerable adults, The Appropriate Adult Service (TAAS) is available between 9am and 9pm on weekdays and 10am and 8pm at weekends. An emergency service is available outside these hours, subject to an inspector’s approval. Once requested, TAAS representatives should attend custody as soon as possible.

Bristol and Somerset Youth Justice Service teams provide AA support for children. Youth Justice Service teams are available between 9am and 9pm and don’t provide an overnight service. They should attend custody within one hour of the request.

Throughout our inspection, we received different views about who has responsibility for arranging an AA. Some custody personnel and Youth Justice Service representatives told us that this fell to investigating officers.

When attending incidents, some arresting officers try to identify suitable relatives or friends to act as an AA if they think a detainee needs this support while they are in custody.

Information relating to AAs on custody records was often lacking or confusing. For example, some custody records showed the time an AA was requested as the same time they arrived in custody.

The force meets with its partners who provide AA services to monitor performance, but it doesn’t routinely gather its own data to help it understand how well these arrangements are working.

Children

The force is proactive in keeping children out of custody wherever possible. Custody officers are encouraged to speak with frontline officers at incidents to discuss whether there are alternatives to arrest and detention.

Frontline officers told us that custody officers take a robust approach when deciding whether to authorise detention. During our inspection we saw some good examples where custody officers appropriately refused to detain children. From our case reviews we were satisfied that, when children were detained in custody, it was necessary and justified.

However, data provided by Avon and Somerset Police shows that the number of children detained in custody has increased over the last three years. The force has recognised this and has sought to understand the reasons for it.

Some frontline officers and custody personnel we spoke to said that custody officers prioritise booking in children. We saw one example of this happening during our inspection. But the force has no standard procedure for prioritising children, and it is left to the discretion of individual custody officers.

In all the cases we looked at, custody officers followed the force’s policy to complete a children and young person detention certificate for each child in custody.

When children are detained in custody, it is often for lengthy periods. The force’s own data shows that on average children spend a longer time in custody before charge compared with adults, and for longer than we usually see.

The force told us that longer detention times reflected their approach of only detaining children for serious offences. As a result, the investigations are more complex and continue for extended periods. The force monitors this and has some understanding of the longer detention times for children.

However, we did find some delays, which were due to difficulties in finding a suitable AA, and PACE reviews didn’t always give enough attention to whether investigations were expeditious. We didn’t find evidence in custody records or from our observations that custody officers were actively seeking the progress of investigations to minimise detention time.

It is a requirement under section 31 of the Children and Young Persons Act 1933 that all girls in custody under the age of 18 are allocated a female officer or member of staff to oversee their care and welfare needs. In the records we looked at we found little evidence of this.

The force told us that custody senior officers and their teams had a good awareness of this requirement and that it routinely happened. But the lack of recording makes it difficult to accurately assess whether girls in custody are receiving the appropriate support.

The custody superintendent meets regularly with the force’s local authority partners to discuss the management of children in custody. These meetings include regional custody review panels with each of the five local authorities in the force area. The panels scrutinise cases of detained children and seek to identify learning opportunities.

However, this is not resulting in more children moving to local authority accommodation instead of staying in police detention overnight. In the 12 months up to our inspection, 61 children were charged and refused bail. In such cases, the custody officer has a duty under section 38 of PACE 1984 to secure the transfer of these children to local authority accommodation. However, requests for local authority accommodation were made in only 42 cases. The force had no record of a request being made in the other 19 cases and couldn’t explain this. Of the 42 requests, only one child was moved into local authority accommodation.

We reviewed three cases in detail and found little information about decisions taken by custody officers or evidence of escalation to senior managers. The force recognises that that more needs to be done with partners at a strategic level to address this issue. But it needs to make sure requests are always made and recorded where required by section 38 of PACE 1984, and then monitor the outcomes so it can effectively hold the local authority to account.

Healthcare

Mitie Care & Custody provides physical healthcare support to detainees, and forensic testing in custody. HCPs are allocated to each custody suite and provide healthcare cover 24 hours a day, 7 days a week. Senior HCPs are available daily to support the service and can cover the rota if there are staff shortages.

Mitie has a contractual target to see 95 percent of detainees within 60 minutes, but between August and November 2023 it routinely fell below this. Where Mitie doesn’t provide cover as required by the contract, the force can apply financial penalties. The force and Mitie are reviewing whether the 60-minute response requirement is practical due to the force’s large geographical area.

Mitie has recently recruited more HCPs, which is positive. From the end of January 2024, these new staff will have completed their induction and the rota cover should be at an average of 97 percent.

Avon and Wiltshire Mental Health Partnership NHS Trust provides L&D services at Patchway and Keynsham and sub-contracts Somerset NHS Foundation Trust to provide services at Bridgwater. NHS England directly commissions L&D services and monitors the contract together with the force.

Partnership working between the force and its healthcare partners is good. Governance processes provide a strategic overview and create a cohesive approach to monitoring safety, quality and the performance of health services. As the lead provider, Mitie shares and reviews data with the force at monthly contract review meetings. It also carries out a regular clinical audit of care records, medicines, and infection prevention and control. Action is taken to improve the quality of care for detainees.

Healthcare and L&D staff receive relevant training for their roles, including safeguarding training to make sure they are competent in recognising vulnerabilities in detainees. Their performance is appraised each year. All staff can access clinical supervision.

Each custody suite has a medical room that is used solely by HCPs. All medical rooms are compliant with infection, prevention and control guidance and are cleaned daily. However, the force removed the doors to the clinical rooms and replaced them with privacy curtains. This doesn’t allow for full patient confidentiality or dignity. On one occasion during our inspection, we saw a detainee being assessed by an HCP while the curtain was open.

Each of the three custody suites has a dedicated forensic sampling room, which is forensically cleaned before and after examinations. At the time of our inspection, we found the rooms were sealed and certified as clean.

There is essential emergency equipment in all medical rooms. All suites have police-owned, automated external defibrillators that are easily accessible. HCPs and custody personnel regularly check this equipment to make sure it is fit for purpose and ready for use.

Healthcare staff have access to interpreters for detainees whose first language is not English.

All health providers report incidents through their electronic reporting systems. Incidents are investigated and learning is shared with staff through meetings and supervision.

All healthcare providers have a confidential complaints process. They have received few complaints in the last 12 months.

Physical health

Detainees mostly receive prompt clinical assessment. Experienced and competent HCPs provide treatment for detainees. They enjoy their role and feel well supported. HCPs clinically triage calls and prioritise treatment based on clinical need. If required, they have access to more senior staff and doctors for clinical advice, including out of office hours.

Custody personnel we spoke with recognised that there had been HCP staffing shortages, but overall were positive about HCPs and reported good working relationships. When detainees need to see an HCP, custody officers phone the Mitie call centre to log requests. HCPs regularly monitor their system to check for new requests and make sure they respond in a timely manner.

Clinical rooms are well equipped and comply with infection control guidelines. Subject to risk, detainees are seen in private.

HCPs request consent from detainees to carry out assessments of physical and mental health, including their mental capacity. This consent includes allowing HCPs to access a summary of the detainee’s community health records, including any prescribed medication.

HCPs taking intimate samples do so in dedicated and appropriately cleaned medical rooms. An officer is present, but dignity curtains are in place to create privacy for the detainee.

HCPs record a summary of actions they have taken on a detainee’s custody record, including assessments and treatment. This makes sure that custody personnel and L&D staff are aware of the detainee’s healthcare needs. They record further detail on their own electronic recording system. HCPs contribute to decisions regarding risk and fitness to detain or release, and fitness for interview.

Mental health

NHS England commissions the L&D team to provide a service to detainees that covers all types of vulnerabilities, including those relating to social needs and health. The service operates as Advice and Support in Custody and Court (ASCC). These partnership arrangements are good and NHS commissioners provide effective oversight.

Staff from ASCC are based in all three suites seven days a week between 8am and 8pm. The service can be limited due to staffing shortages, but the team work flexibly and can provide the service remotely when they can’t cover each suite in person. At the time of our inspection, ASCC managers were working hard to address staffing needs and recruitment was progressing well.

Custody personnel make referrals for the L&D service directly to ASCC. The teams based at Keynsham and Patchway also proactively screen all detainees to identify vulnerabilities and a need for the service. ASCC staff provide assessment and make referrals to community engagement workers based on individual need. They prioritise women and children. Peer mentors support detainees following their release from custody. It was positive to see that ASCC provides detainees with written information about community-based services when they leave custody.

ASCC has dedicated staff to support children and young people in custody and to provide the drug education programme. ASCC staff at Patchway and Keynsham see voluntary attendees on site, but this service is not yet available at Bridgwater.

ASCC staff can access custody records to record information. In addition, they speak with or email custody personnel to pass on relevant information about detainees. But our custody record audits identified inconsistent or incomplete recording of some information by ASCC staff. This means there is a risk that custody records may not always reflect the latest information about detainee care.

It is positive that the force doesn’t use custody as a place of safety under section 136 of the Mental Health Act 1983. However, detainees who are already in custody who later present with suspected mental health problems are sometimes kept in custody under section 136 while waiting for an assessment. In the year leading up to our inspection, the force used this power on 190 occasions. There are only seven beds at health-based places of safety in the force’s geographical area, which means there can be delays in detainees accessing the support they need.

The force doesn’t gather data on the number of Mental Health Act assessments carried out in custody. Data provided by the ASCC teams showed that 78 assessments had been completed in custody in the 12 months before our inspection. Of these, 35 were completed at Patchway.

No data was available on the time detainees spent in custody under the Mental Health Act while they waited for an assessment. The force has arrangements with ASCC to identify and escalate situations if a detainee remains in custody for over 24 hours. In our custody record audits, we found just one case where a detainee spent over 24 hours in custody.

We found that the absence of agreed processes in custody and the limited availability of beds in health-based places of safety were contributing to the use of section 136 to move detainees from custody.

The force has no standard process or guidance for custody personnel to follow if detainees need Mental Health Act assessments outside the ASCC team’s operating hours. Custody personnel told us that they would make referrals to ASCC for the following day. This practice potentially disadvantages detainees held overnight in custody with acute mental health issues.

Five different local authorities cover the force’s geographical area, and each one has different arrangements for providing out-of-hours mental health services. An approved mental health professionals service covers Bridgwater 24 hours a day, 7 days a week. However, there is only one emergency duty team covering Patchway and Keynsham between 10pm and 8am. The availability of doctors after 10pm is minimal. The use of section 136 by the force to detain a person in the community and take them to a mental health facility is high. In the 12 months prior to our inspection, section 136 was used on 1,685 occasions.

Under the umbrella of the Integrated Access Partnership, Avon and Wiltshire Mental Health Partnership NHS Trust provides a range of support and advice to frontline officers for dealing with people with mental health conditions. This includes emergency services triage, a telephone helpline and a rapid response vehicle. Mental health teams can provide advice such as alternatives to using section 136 in the community.

Staff from Avon and Wiltshire Mental Health Partnership NHS Trust work in the emergency services operations centre as part of the integrated access partnership, providing advice and support to all emergency service colleagues.

The force is proactive in identifying, supporting and managing people with mental health concerns in custody and in the community. It is ambitious and committed to continuous improvement and innovation in this area. This includes the use of a mental health tactical advisor, mental health advice plans for regular contacts, and panels that scrutinise the use of section 136.

Substance misuse

HCPs provide an initial assessment and, where required, treatment for detainees experiencing drug and alcohol withdrawal while in custody. They use nationally recognised assessment tools to inform their decision-making. When clinically necessary, staff administer medicines to detainees to relieve symptoms of withdrawal.

HCPs support detainees already in treatment in the community to continue opiate substitute treatment while in custody. There are appropriate patient group directions to support this. These offer a framework that lets some registered health professionals administer specific medicines to particular groups of patients without them seeing a prescriber. Some HCPs are also prescribers.

The patient group directions help staff make decisions on various health issues, including pain relief and acute withdrawal from alcohol and drugs. The force can provide nicotine replacement therapy on request.

ASCC provides the substance misuse service at all three custody suites. Staff see detainees with drug and alcohol problems while they are in custody and make referrals to community providers of substance misuse treatment. ASCC has dedicated drug education programme workers who work in and out of custody.

The force runs an initiative to automatically carry out a drug test for detainees arrested for specific offences to reduce drug-related offending. The force provides this in partnership with drug education programme workers from Avon and Wiltshire Mental Health Partnership NHS Trust.

Medicines management

HCPs provide medicines for detainees following assessment and in line with the patient group directions provided by Mitie.

Mitie has robust governance arrangements to manage medicines, including regular checks and audits by HCPs and Ashtons Pharmacy Services. HCPs use appropriate systems and processes to safely administer, record and store medicines and receive regular training.

Controlled drugs are managed safely by HCPs, and they complete regular audits of medicines to identify any potential errors. HCPs report medicine errors through Mitie’s incident reporting system, and managers investigate these promptly and share learning with staff. Custody personnel store detainees’ own labelled medicines in the property lockers and, with support from HCPs, these are provided to detainees at scheduled times.

Detainees’ own medicines are transferred to court with them. Where possible, detainees who don’t have their own supply of medicines are given any medicine they need before leaving custody to go to court. However, there is no provision for such medicines to be transported to court with the detainee.

Section 5. Release and transfer from custody

Expected outcomes: Release and transfer from custody

Detainees are released or transferred from custody safely. Those due to appear in court in person or by video do so promptly.

Safe release and transfer arrangements

Custody officers generally carry out pre-release risk assessments with the detainee present, but this doesn’t always happen when detainees are released to court.

Pre-release risk assessments contain limited reference to the risk assessments carried out when detainees arrive in custody, or to risks identified while they are detained. The assessments are based on a set of standard questions, with the option to select yes or no answers from a drop-down menu. There is also the option to expand on answers with free-text entries, but we found that custody officers rarely used this. This means they aren’t considering all risks and discussing these with the detainee before they are released.

Custody officers don’t always make a record on the pre-release risk assessment about how a detainee is getting home. The force has arrangements with local bus companies to provide tickets to detainees, but we found that these are not always offered unless a detainee asks for help to get home.

The ASCC team provides support and takes responsibility for detainees’ welfare needs when they are released from custody. The team speaks with detainees in custody and leaves leaflets in detainees’ property. All custody suites have a good supply of leaflets, which include information about support for alcohol and drug misuse and how to make a complaint about the police. We saw a good example of ASCC supporting a detainee, where the charity Op NOVA, which provides support to military veterans in contact with the justice system, arranged a same-day appointment with a veteran following his release from custody.

When ASCC staff aren’t in custody suites, custody officers don’t always offer these support leaflets to detainees. And they don’t always talk to detainees about the help available in the community.

Some custody officers we spoke to weren’t aware of the enhanced safeguarding arrangements for those arrested on suspicion of committing serious sexual offences, or their responsibility to make sure that the correct procedures are followed.

There was some confusion about whether this was the responsibility of investigating officers or part of the custody pre-release risk assessment.

When detainees are released to court, detention officers manage the pre-release process and take responsibility for the risk and handover of detainees without any oversight from custody officers. Detainees aren’t always present when these risk assessments are carried out.

Detention officers also complete digital person escort records. Custody officers don’t have any oversight of this process. They don’t sign off the forms or supervise the handover of detainees to the external contractor Serco. This is contrary to APP guidance. Custody officers weren’t aware of their responsibilities and don’t have access to the digital person escort record systems.

During the handover process we didn’t see custody personnel speaking with Serco staff about detainee risks. There are no checks to make sure that Serco staff understand the individual risks for each detainee.

The force cannot assure itself that is safely managing risk when detainees are released from custody. This forms part of our cause of concern.

Courts

Detainees appear before the local court in person and in appropriate clothes. They are transferred to the next available court. The force’s external contractor Serco takes detainees to court, but its arrival times at custody range between 8am and 11am. This can make it difficult for custody personnel to plan when detainees are leaving custody.

There are no agreed cut-off times with the courts, and custody officers told us that courts will generally take late admissions up to 2pm. Police officers promptly take these detainees to court, as Serco will rarely accommodate afternoon admissions.

The force has functional virtual courts but has rarely used them since the pandemic.

Section 6. Summary of causes of concern, recommendations and areas for improvement

Causes of concern and recommendations

Areas for improvement

Leadership, accountability and partnerships

In the custody suite – booking-in, individual needs and legal rights

In the custody cell – safeguarding and healthcare

Release and transfer from custody

Section 7. Appendices

Appendix I – Methodology

Police custody inspections focus on the experience of, and outcomes for, detainees from their first point of contact with the police and throughout their time in custody to their release. We visit the force over two weeks. Our methodology includes the following elements, which inform our assessments against the criteria set out in our ‘Expectations for police custody’.

Document review

Forces are asked to provide various important documents for us to review. These include:

• the custody policy and/or any supporting policies, such as the use of force;
• health provision policies;
• joint protocols with local authorities;
• staff training information, including officer safety training;
• minutes of any strategic and operational meetings for custody;
• partnership meeting minutes;
• equality action plans;
• complaints relating to custody in the six months before the inspection; and
• performance management information.

We also request important documents, including performance data, from commissioners and providers of health services in the custody suites and providers of in-reach health services in custody suites, such as crisis mental health and substance misuse services.

Data review

Forces are asked to complete a data collection template based on police custody data for the previous 36 months. The template requests a range of information, including:

• custody population and throughput;
• the number of voluntary attendees;
• the average time in detention;
• children; and
• detainees with mental health problems.

This information is analysed and used to provide background information and to help assess how well the force performs against some main areas of activity.

Custody record analysis

We analyse a sample of custody records drawn from all detainees entering custody over a one-week period prior to the start of our inspection. The records are stratified to reflect throughput at each custody suite and are then picked at random. Our analysis focuses on the legal rights and treatment and conditions of the detainee.

Case audits

We audit around 40 case records in detail (the number may increase depending on the size and throughput of the force inspected). We do this to assess how well the force manages vulnerable detainees and specific elements of the custody process. These include examining records for children, individuals with mental health problems, those under the influence of drugs and/or alcohol, and cases where force has been used on a detainee.

Our audits examine a range of factors to assess how well detainees are treated and cared for in custody. Audits examine, for example, the quality of risk assessments, whether observation levels are met, the quality and timing of PACE reviews, whether children and vulnerable adults get support from appropriate adults when they need it, and whether detainees are released safely. We also assess whether force used against a detainee is proportionate and justified, and is properly recorded.

Observations in custody suites

Inspectors spend a significant amount of their time during the inspection in custody suites assessing their physical conditions, observing operational practices, and assessing how detainees are treated. We speak directly to operational custody officers and staff, and to detainees to hear their experience first-hand. We also speak to other non-custody police officers, solicitors, health professionals and other visitors to custody to get their views on how custody services operate. We examine custody records and other relevant documents held in the custody suite to assess how detainees are dealt with, and whether policies and procedures are followed.

Interviews with personnel

During the inspection we interview officers from the force. These include:

• chief officers responsible for custody;
• custody inspectors; and
• officers with lead responsibility for areas such as mental health or equality and diversity.

We speak to people involved in commissioning and running health, substance misuse and mental health services in the suites and in relevant community services, such as local Mental Health Act section 136 suites. We also speak to the co-ordinator for the Independent Custody Visitor scheme for the force.

Focus groups

During the inspection we hold focus groups with frontline response officers and response sergeants. The information gathered informs our assessment of how well the force diverts vulnerable people and children from custody at the first point of contact.

Feedback to force

The inspection team provides an initial outline assessment to the force at the end of the inspection, to give it the opportunity to understand and address any concerns at the earliest opportunity. Then we publish our report within four months giving our detailed findings and recommendations for improvement. The force is expected to develop an action plan in response to our findings, and we make a further visit about one year after our inspection to assess progress against our recommendations.

Appendix II – Inspection team

• Norma Collicott: HMICFRS inspection lead
• Mark Calland: HMICFRS inspection officer
• Anthony Davies: HMICFRS inspection officer
• Nicola Duffy: HMICFRS inspection officer
• Julie Mead: HMICFRS inspection officer
• Nikki Smith: HMICFRS inspection officer
• Andrew Reed: HMICFRS inspection officer
• Emmanuelle Versmessen: HMICFRS inspection officer
• Justine Wilson: HMICFRS inspection officer
• Catherine Raycraft: CQC inspector
• Joanne White: CQC inspector

Fact page

Note: Data supplied by the force.

Force

Avon and Somerset Police

Chief constable

Sarah Crew

Police and crime commissioner

Mark Shelford

Geographical area

Bristol, Bath and Northeast Somerset, South Gloucestershire, North Somerset, South Somerset, West Somerset

Date of last police custody inspection

August 2016

Custody suites

• Bridgwater: 36 cells
• Keynsham: 48 cells
• Patchway: 48 cells

Annual custody throughput

12 months to December 2023 – 18,462

Custody staffing

• One chief inspector
• Ten inspectors, including a development post
• 60 custody officers
• 90 detention officers

Health service provider

Mitie Care & Custody

Back to publication

Report on an inspection visit to police custody suites in Avon and Somerset Police