Report on an inspection visit to police custody suites in Cambridgeshire Constabulary

Summary

This report describes our findings following an inspection of Cambridgeshire Constabulary custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and the Care Quality Commission (CQC) in April 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.

To help the constabulary improve, we have highlighted 12 areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and working with partners

Cambridgeshire Constabulary has clear governance structures for its custody services, with established arrangements to oversee the safe and respectful provision of custody. These include strategic and operational meetings where custody services are discussed. We found senior managers showing a keen interest in custody.

The constabulary manages its custody services across two suites at Parkside in Cambridge and Thorpe Wood in Peterborough. The custody estate is dated, and some facilities don’t meet detainee needs. But the suites are clean and well maintained, particularly at Peterborough. The constabulary recognised the Cambridge suite needed improvement and is currently building a new suite at Milton, Cambridge, which is due to open in 2025. It is also investing in further improvements in the Peterborough suite.

At the time of our inspection, there were no staffing vacancies. There were generally enough personnel on each shift to provide custody services but the constabulary relies heavily on resilience officers from response and neighbourhood teams to fill gaps, especially at Parkside. We saw custody personnel overstretched when the suites were busy. This sometimes adversely affected detainees, because it led, for example, to fewer offers of showers and exercise. There aren’t always enough inspectors available to carry out relevant custody duties. This means that inspectors sometimes don’t have enough time to carry out reviews of detention appropriately, especially when they are carrying out the force duty manager role as well.

Initial training for both custody officers and detention officers follows the nationally approved course developed by the College of Policing.

The constabulary has adopted the College of Policing’s authorised professional practice (APP) guidance, but there are areas where it isn’t always followed, particularly when managing risk. Custody personnel don’t always follow the Police and Criminal Evidence Act 1984 (PACE), its codes of practice, and other legislation. Although we found custody personnel usually give detainees their rights and entitlements in line with PACE code C, custody inspectors didn’t always complete or record reviews of detention well. And it wasn’t always clear whether custody personnel allocated girls under 18 to the care of a female member of staff, as required by the Children and Young Persons Act 1933.

Cambridgeshire Constabulary collects and monitors different information to show how well its custody services perform. This includes:

• the number of detainees entering custody and those refused detention;
• the number of children in custody;
• waiting times for appropriate adults provided by The Appropriate Adult Service (TAAS);
• data on strip searching in custody by age, gender and ethnicity; disproportionality outcomes by ethnicity;
• the number of detainees who are bailed and released under investigation; and
• use of force incidents in custody.

But it isn’t always clear how the findings are used to improve services. And some data is inaccurate or not collected. The constabulary only monitors appropriate adult (AA) request and arrival times when the AA is provided by TAAS but not when a family member or friend acts as the AA. The constabulary’s failure to record and monitor such areas of performance limits its ability to strategically improve and influence better outcomes for detainees.

The constabulary’s governance and scrutiny of the use of force in custody isn’t good enough. It considers use of force at both the custody strategy and use of force panels, and there is some quality assurance of incidents. However, the constabulary doesn’t always record use of force incidents properly, and sometimes it doesn’t record them at all. Not all personnel involved in an incident complete the required use of force forms. Cambridgeshire Constabulary therefore can’t always show that when its personnel use force in custody, it is necessary, justified and proportionate. This area requires immediate attention and is one of our recorded areas for improvement.

The constabulary understands its responsibilities under the public sector equality duty and has policies and guidance to reflect these. Training for custody personnel on equality, diversity and inclusion has been provided online and through annual continuing professional development (CPD).

The constabulary collects information to help it assess whether outcomes for detainees are fair. It breaks down arrests, strip searches, general outcomes and any use of force incidents in custody by ethnicity, gender and age.

There is a clear priority to divert children and vulnerable adults away from custody. Frontline officers and custody personnel understand this and work to achieve it where possible.

Pre-custody – first point of contact

Frontline officers have a good understanding of what makes a person vulnerable. For example, they consider age, substance misuse, and mental health conditions as factors that can influence vulnerability. They take account of any such factors, and the need to keep a person safe, when deciding whether to arrest. They use alternatives to custody, such as voluntary attendance or community resolutions. They only take children into custody as a last resort.

There is good support for frontline officers dealing with people with mental health conditions. This includes a mental health triage service of two cars staffed with police officers and mental health professionals. The triage service provides advice and assistance to officers and attends incidents to deal with people directly. There is also a mental health practitioner working in the control room during the day and evenings to provide additional support to frontline officers. Frontline officers told us this support helps them decide what to do. Sometimes it helps them avoid detaining a person under section 136 of the Mental Health Act 1983, because more appropriate health solutions were provided instead.

When people are detained under section 136, they are usually taken to an accident and emergency department at a local hospital or to the dedicated mental health-based place of safety at Fulbourn (known as the section 136 suite). Officers said they usually wait a long time with the person before handing them over to the health service.

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

Custody personnel show respect to detainees and are generally patient and reassuring during their interactions with them. There is limited privacy for detainees in both suites. But Thorpe Wood has a discrete booking-in area that can be used to book in children and vulnerable adults.

Custody personnel generally understand the needs of detainees from protected or minority groups and do their best to meet these needs. The suites have limited facilities to meet the needs of detainees with physical disabilities but provision for those with visual or hearing impairments is better.

During booking-in, custody officers usually ask if detainees wish to speak to an officer in private. They don’t routinely offer female detainees a female officer as a point of contact during their time in custody, although it is good practice to do so. There is good provision for detainees who speak limited or no English. The constabulary uses Language Line for detainees who need interpreters. Detainees can observe their faith and there is a suitable range of religious items at both custody suites. These items are stored respectfully.

Custody personnel generally identify and manage risk well, but they don’t always reflect this in custody records. The constabulary doesn’t follow APP guidance in all areas of risk management.

Custody personnel generally book detainees in promptly. But during busy periods some detainees can spend a long time waiting in vans or holding areas. Not all custody officers we saw assessed risk and prioritised vulnerable adults or children. The booking-in process is thorough and custody officers clearly explain the procedures. They appropriately authorise detention and consider welfare and the needs of vulnerable detainees. Custody officers clearly explain legal rights and entitlements to detainees.

Reviews of detention don’t always comply with the requirements of the PACE codes of practice. Custody inspectors don’t always carry them out well enough, or in the best interests of the detainee. We gave the constabulary feedback during our inspection due to the concerns we had, and leaders took immediate action by briefing custody personnel. We subsequently saw some improvements in the thoroughness of reviews done in person and in the standard of recording.

In the custody cell – safeguarding and healthcare

The custody estate in Cambridgeshire has two full-time designated suites at Parkside and Thorpe Wood, and two contingency units at Huntingdon and March that are used when the main suites are closed. There are potential ligature points in all the suites. The constabulary has recognised the limitations of its custody estate and is currently building a new custody unit at Milton in Cambridge to replace Parkside custody suite from 2025.

The constabulary’s approach to detainee care is good. During booking-in, custody personnel tell detainees about their entitlements to food and drink, showers, exercise and reading material.

Custody personnel recognise the importance of safeguarding children and vulnerable adults while in custody and on their release. Where necessary, investigating officers complete safeguarding forms for children and vulnerable adults. They discuss safeguarding concerns with custody officers to make sure that any risks of harm are minimised both inside and outside custody suites.

The constabulary has recently implemented a process for children who are brought into custody. This requires custody personnel to make immediate contact with children’s social services and the force multi-agency safeguarding hub in order to exchange risk and safeguarding information. This process is referred to as the golden hour process for dealing with children in custody. This early contact with partner organisations aims to get the best outcomes for detained children.

Girls held in custody are required to have a same-sex member of staff assigned to safeguard and monitor their welfare while in custody as per the Children and Young Persons Act 1933. But in the cases we examined it wasn’t clear if this had happened as it wasn’t recorded. In most cases AAs attend custody promptly, but some children and vulnerable adults wait a long time for an AA.

Frontline officers and custody personnel focus on diverting children away from custody where possible. Where children are charged and remanded into custody, they should be moved to alternative accommodation arranged through the local authority while they are waiting to appear in court. Despite the constabulary’s work with the local authority to improve the provision of alternative accommodation, progress has been limited since our last inspection.

Experienced and competent healthcare professionals (HCPs) provide treatment for detainees. Where required, HCPs also have access to more senior staff for clinical advice, including out of hours. There is good support for detainees with substance misuse needs, and medicines are stored appropriately.

Liaison and diversion staff provide good support to vulnerable detainees in custody. Support and onward referral options are available for detainees with mental health and drug and alcohol issues, as well as those with housing and social problems. The constabulary has a process in place for when an assessment under the Mental Health Act 1983 is needed, both during the day and out of hours. After midnight however, there is minimal availability of doctors, who are needed as part of this assessment. There is only one section 136 suite, and it is often in use. This means that officers have to take detainees to the accident and emergency department.

Release and transfer from custody

Custody personnel focus on helping all detainees get home safely but especially children and vulnerable adults. However, custody officers don’t always complete and record a thorough pre-release risk assessment while with the detainee. Detention officers complete digital person escort records and arrange transport for detainees who are attending court or for those recalled to prison. They complete these records well and include relevant risk, health and medication information. Custody officers check the records, but don’t otherwise have much involvement with, or oversight of, the release of these detainees. Custody officers don’t routinely speak with detainees leaving custody to complete a pre-release risk assessment with them. These practices don’t follow APP guidance.

When detainees are remanded, they aren’t always transferred promptly to the next available court. The organisation that is contracted to escort detainees to court isn’t consistent with its attendance times and sometimes attends late. Detainees appear before a local court in person, but sometimes the courts don’t have the capacity to accept all remanded detainees at the same time. This results in some detainees being transferred later in the day or attending the court through video link facilities. This lengthens their stay in police custody and is a poor outcome.

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 PACE 1984, its codes of practice and the College of Policing’s authorised professional practice – 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 Cambridgeshire Constabulary, 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

Cambridgeshire Constabulary has clear governance structures for its custody services, with established arrangements to oversee the safe and respectful provision of custody. The police and crime commissioner also provides oversight. Senior managers show a keen interest in custody. Since our last inspection in 2017, the constabulary has made good progress in some areas, after it removed itself from a tri-force custody collaboration with Bedfordshire and Hertfordshire. The constabulary also responded quickly to our feedback during the inspection and started making some improvements immediately.

An assistant chief constable oversees custody services, supported by a chief superintendent. A chief inspector and two inspectors are responsible for the day‑to‑day management of custody services.

The constabulary has strategic and operational meetings to oversee and manage custody services:

• The head of criminal justice chairs a criminal justice custody senior leadership meeting, to examine all aspects of custody provision and performance.
• A chief inspector chairs a newly formed custody delivery group, which oversees important areas of custody and includes a public panel for increased transparency.
• An assistant chief constable chairs a monthly force performance board.

There are effective scrutiny and management arrangements in place for the new healthcare contract, which commenced five weeks before our inspection. We noticed some early contractual issues, but senior managers were aware of these and are addressing them with the new contractor.

There are two operational custody suites at Parkside and Thorpe Wood, and two contingency units at Huntingdon and March that are used when the main suites are closed. The custody estate is dated, and some facilities don’t meet detainee needs. For example, there are limited sinks available in cells and the facilities for physically disabled detainees are generally poor. But the suites are clean and well maintained, particularly at Peterborough.

The constabulary recognised the suite at Cambridge needed improvement and is building a new suite at Milton, Cambridge. This is due to open in 2025. It is also investing in further improvements in the suite in Peterborough. This includes adapted showers for those with limited mobility, as well as mood lighting in some cells to help those with neurodivergent conditions. We gave the constabulary a physical conditions report illustrating potential ligature points within all four suites as well as their general conditions. It accepted this report and moved quickly to address some of the issues we found in order to mitigate risk.

The constabulary has 26 full-time custody officers, 24 detention officers, and 2 inspectors to oversee custody services. At the time of our inspection there were no vacancies. We saw that there were generally enough personnel on each shift to provide custody services, but the constabulary relies heavily on ‘resilience personnel’ to fill gaps, especially at Parkside. The resilience pool consists of operational police sergeants and police officers on response and neighbourhood teams who are trained as custody officers and detention officers.

The constabulary has made sure that the operational sergeants have completed the full nationally approved training, developed by the College of Policing, so that they are professionally competent to fulfil the role of custody officer. But police constables acting as detention officers only receive limited training. This means they can only carry out certain detention officer functions but aren’t trained to take biometric samples, for example. This, in turn, means that the full-time detention officers have to complete more work.

We saw custody personnel overstretched when the suites were busy. This sometimes adversely affected detainees, such as when it led to fewer offers of showers and exercise. There aren’t always enough inspectors available to carry out relevant custody duties. This means that inspectors sometimes don’t have enough time to carry out reviews of detention appropriately, especially when they are carrying out the force duty manager role as well. Custody personnel also said that inspectors aren’t always available to record complaints before a detainee leaves custody.

Initial training for custody officers and detention officers follows the nationally approved course. The constabulary is no longer part of a tri-force arrangement, but the training is still carried out by the tri-force training team. As this covers three forces, this means that course slots aren’t always easily available. All custody personnel attend a three-week course, followed by a shadowing period, before starting their duties.

The constabulary provides up to five days of CPD training annually. Recent topics have included recognising and dealing with vulnerability, mental health, and menopause awareness. But officers and staff told us training could be better and they would like more sessions on vulnerability and neurodivergence. Internal messaging and computer-based training provides information and awareness and includes learning from any adverse incidents in custody. Guidance is also available on the force intranet and in the constabulary’s overarching standard operating procedure for custody.

The constabulary has adopted the College of Policing’s APP guidance, but there are areas where it isn’t always followed, particularly when managing risk. For example, clothing with cords is frequently removed without an individualised risk assessment, and custody officers don’t always oversee the release process when detainees are transferred to courts.

Custody personnel don’t always follow the Police and Criminal Evidence Act 1984 (PACE), its codes of practice and other legislation. Although we found custody personnel usually give detainees their rights and entitlements in line with PACE code C, custody inspectors didn’t always carry out or record reviews of detention well. And it wasn’t clear if girls under 18 were allocated to the care of a female member of staff as required by the Children and Young Persons Act 1933. The constabulary needs to make some immediate improvements to consistently meet the requirements of PACE code C regarding reviews of detention.

The constabulary appropriately records adverse incidents (any incident that, if allowed to continue to its ultimate conclusion, could have resulted in death or serious injury to any person). It shares learning from incidents with its workforce. There have been no deaths in custody suites in Cambridgeshire since our last inspection.

Accountability

Cambridgeshire Constabulary collects and monitors different information to show how well custody services perform. Performance data is comprehensive and monitored at regular custody meetings chaired by the chief inspector, as well as at force performance meetings. Examples of areas monitored include:

• the number of detainees entering custody and those refused detention;
• children in custody and waiting times for appropriate adults provided by TAAS;
• strip searching in custody by age, gender and ethnicity;
• disproportionality outcomes in custody by ethnicity;
• the number of detainees who are bailed and released under investigation; and
• use of force incidents in custody.

Quality assurance arrangements are in place. Custody inspectors and custody officers dip sample records each month from the two suites and check them against a set of indicators. Despite this, the constabulary hadn’t identified some of the concerns we found. The quality assurance process focuses on whether something has been done, rather than on how well it has been done. It isn’t clear how the constabulary uses any quality assurance findings, especially when they show themes or trends, to make improvements.

The constabulary doesn’t collect some data that would be useful, and in some instances the data it collects is inaccurate. It only records and monitors AA request and arrival times when the AA is provided by TAAS, not when a family member or friend acts as the AA. The failure to record and monitor such areas of performance limits the constabulary’s ability to strategically improve and influence better outcomes for detainees.

The constabulary’s governance and scrutiny of the use of force in custody isn’t good enough. It considers use of force at both the custody strategy and use of force panels, and there is some quality assurance of incidents. However, the constabulary doesn’t always record use of force incidents properly, and sometimes it doesn’t record them at all. Not all personnel involved in an incident complete the required use of force forms. This means the information used by Cambridgeshire Constabulary to support effective scrutiny is sometimes inaccurate.

In our CCTV review, we found that custody personnel don’t always manage use of force incidents well. In four cases, we had concerns about the poor use of techniques. We referred these cases to the constabulary for its own review. It isn’t clear how its quality assurance arrangements would pick up the types of concern we identified. This is because the arrangements don’t examine the quality of recorded entries, or the proportionality and type of techniques used.

Cambridgeshire Constabulary therefore can’t always show that when its personnel use force in custody, it is necessary, justified and proportionate. This area requires immediate attention and is one of our recorded areas for improvement.

The quality of entries on custody records is sometimes poor. We found custody personnel sometimes left out important information, such as the justification for the removal of clothing, or elements of reviews of detention. Sometimes they didn’t record the provision of food and drink at all, and information about what happens during cell visits wasn’t clear. Custody personnel often rely on standard prepopulated text entries, or identical text to the previous entry, when recording welfare checks and reviews of detention. This is poor practice and makes it difficult to assess any improvement or deterioration in a detainee’s condition.

The constabulary understands its responsibilities under the public sector equality duty and has policies and guidance to reflect these. It has provided training for custody personnel on equality, diversity and inclusion, via online courses and through annual CPD. Recent areas of training have included modules on cultural awareness, sexuality awareness, disability and valuing difference.

The constabulary collects information to help it assess whether outcomes for detainees are fair. It breaks down the data for arrests, strip searches, general outcomes and any use of force incidents in custody, by ethnicity, gender and age. To date, the constabulary hasn’t identified any specific concerns about disproportionality, but it intends to closely monitor this information in future to see if any trends emerge.

The Independent Custody Visiting Association (ICVA) scrutinises custody. Independent Custody Visitors (ICVs) visit the suites regularly and report good working relationships with custody personnel, who respond quickly to any issues raised. The visitors have influenced improvements for detainees, such as the provision of reading glasses and colour screen cards for those with dyslexia. The ICV scheme contributes to custody personnel induction training to help their understanding of the ICV role. Senior police managers attend ICV panel meetings, where ICV representatives provide feedback from the custody visits. Panel members discuss and deal with any recurring concerns. The ICVA Quality Assurance Scheme has recently awarded the Cambridgeshire scheme a gold award.

Cambridgeshire’s Office of the Police and Crime Commissioner (OPCC) provides external scrutiny of custody. The OPCC manages the ICV scheme in Cambridgeshire and attends force performance meetings where custody is discussed.

Working with partners

Cambridgeshire Constabulary clearly prioritises diverting children and vulnerable adults away from custody. Frontline officers and custody personnel understand this and work to achieve it where possible.

The constabulary works with mental health services to offer alternatives to custody for people with mental health conditions. It holds meetings with mental health services, and mental health professionals work both in the force control room and in police vehicles to help deal with incidents involving those with mental health conditions. But when these professionals aren’t available, support arrangements are limited, and outcomes for individuals with mental health conditions could be better. Mental health‑based places of safety include one facility at Fulbourn and Cambridgeshire’s accident and emergency departments. Officers and staff told us there are considerable waiting times for assessments under the mental health act at these places.

The liaison and diversion service at both custody units provides valuable support to vulnerable detainees in custody as well as on release. This supports detainees to get help, to try and reduce further offending as well as lead healthier lives.

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 makes a person vulnerable. They consider, for example, age, substance misuse, and mental health conditions as factors that can influence vulnerability. They take account of any such factors, and the need to keep a person safe, when deciding whether to arrest. Officers also told us they sometimes discuss cases with a custody officer or their supervisor before arrest. This helps them to decide if arrest is the right decision, or whether alternative ways of dealing with the incident are more appropriate.

The constabulary has trained officers on vulnerability. Recent training has included the College of Policing’s vulnerability package, disproportionality with stop and search, and some mental health awareness training. But officers told us their main knowledge and understanding came through their experience of policing. They said they would welcome more training in recognising and dealing with vulnerability.

Information to help frontline officers deal with incidents is generally good. Officers told us that call handlers in the control room provide as much information as they can to help them. They said they usually have enough information to help them decide what action to take.

Officers only take children to custody as a last resort. Frontline officers told us they always consider other options to keep children away from custody. These include arranging voluntary attendance interviews or resolving the incident through an out‑of‑court disposal. We also found that custody officers generally applied greater scrutiny when deciding whether to authorise detention for children.

Support for frontline officers dealing with people with mental health conditions is good. This includes a mental health triage service of two cars staffed with police officers and mental health professionals. The triage service provides advice and assistance to officers and attends incidents to deal with people directly. Although this service is only available in the afternoon and evenings, officers spoke highly of it. There is also a mental health practitioner working in the control room during the day and evenings to provide additional support to frontline officers. Frontline officers told us this support helps them decide what to do. Sometimes it helps them avoid detaining a person under section 136 of the Mental Health Act 1983, because more appropriate health solutions were provided instead.

When officers detain people under section 136, they usually take them to an accident and emergency department at a local hospital, or to the dedicated mental health‑based place of safety at Fulbourn (the section 136 suite). Officers said they usually wait a long time with the person before handing them over to the mental health service. This is a poor outcome for the person in mental health crisis as well as a poor use of police time.

Frontline officers usually arrest and take into custody people with suspected mental health conditions who have committed an offence. Once in custody, liaison and diversion staff assess any mental health concerns. However, in the records we examined we sometimes found the detainee waited a long time for a mental health assessment. This sometimes lengthened their time in police custody considerably. The criminal investigation usually continues until an assessment determines that the person should be transferred to a mental health-based place of safety under section 136 of the Mental Health Act. However, in a few of the cases we looked at, it was our view that the person could have been detained under section 136 and taken to a mental health facility, rather than arrested and taken to custody first.

Detainees are normally taken to custody in police vans following the decision to arrest. There are no specific arrangements for transporting detainees with mobility difficulties, but officers said they would make suitable arrangements in discussion with the detainee. People detained under section 136 should be transported to a mental health facility or hospital by ambulance. But because there can be long waits, officers often take the person in a police vehicle.

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 show respect to detainees and are generally patient and reassuring during their interactions with them.

There is limited privacy for detainees at Parkside due to the proximity of the booking‑in desks. Although there is more space at Thorpe Wood and there are screens separating the booking-in areas, privacy is also limited there. Thorpe Wood has a discrete booking-in area that can be used to book in children and vulnerable adults. During our inspection we saw this being used on several occasions. Parkside doesn’t have such a facility.

There is CCTV coverage in the suites and cells. Custody personnel inform detainees about this and explain that the toilet area is obscured from view to respect their dignity. Showers in both suites are sufficiently private but they aren’t step-free at Parkside.

Custody personnel generally do their best to protect detainee dignity. Detainees are usually suitably dressed when moving around the suite and attending interviews. Custody personnel provide them with replacement clothing if their own clothing is removed for safety reasons or for evidence.

Meeting diverse and individual needs

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

The suites have limited facilities to meet the needs of detainees with physical disabilities, but provision for those with visual or hearing impairments is better.

• Both suites have wheelchairs in good condition.
• All suites have thick mattresses.
• All cells at Parkside have sight lines for visually impaired detainees but there are none at Thorpe Wood.
• Both suites have easy read versions of rights and entitlements, but only Parkside could locate a braille copy.
• Both suites have hearing loops.
• Benches in the cells are low although there are some higher benches at Parkside.
• There are no adapted showers in the suites but there is an adapted toilet at Parkside.
• The exercise yards aren’t step-free.

Custody personnel we spoke to had a reasonable knowledge of neurodivergence and said they had received some training in this area. The constabulary provides dyslexia screens in both suites to assist people with reading, and ear defenders for those who are sensitive to noise. There are distraction materials available as well.

None of the cells are adapted with glass panels to help detainees who suffer from claustrophobia or anxiety, or to help manage risk where appropriate. Custody personnel told us that children and vulnerable adults are usually placed in cells near the booking-in area and in cells that have chalkboards that they can write on.

During booking-in, custody personnel routinely ask detainees whether they have caring responsibilities that need to be considered while they are in custody. They also usually ask detainees if they wish to speak to an officer in private. It is good practice for female detainees to be offered a female officer as a point of contact during their time in custody. But we didn’t always see this happening. When a female officer is allocated, it isn’t always clear from the records if they visit the detainee.

There is a good supply of hygiene products in all suites. But some cells don’t have sinks, and this compromises hygiene standards. Custody officers ask female detainees if they need feminine hygiene products at the point of being booked in. The constabulary is in the process of obtaining appropriate items for menopausal women in custody.

Provision for detainees who speak limited or no English is good. The constabulary uses Language Line for detainees who need interpreters. There is sufficient privacy for detainees to speak with interpreters at the booking-in desks using a three-way phone system.

Detainees can observe their faith and there is a suitable range of religious items at both custody suites. These cover the main religions such as Christianity, Islam and Hinduism. The items are stored respectfully.

Risk assessments

Custody personnel generally identify and manage risk well, but they don’t always reflect this in custody records. The constabulary doesn’t follow APP guidance in all areas of risk management.

Custody personnel generally book detainees in promptly. But during busy periods some detainees can spend a long time waiting in vans or holding areas.

During the booking-in process, custody officers focus on identifying risks, vulnerability factors and welfare concerns when completing initial risk assessments with detainees. They interact well with detainees, explaining the purpose of the assessment and asking probing or supplementary questions. They cross-reference information provided by detainees against the Police National Computer and previous custody records to help inform their assessment. And they routinely ask arresting or escorting officers if they have any further relevant information.

But we found not all custody officers assessed risk and prioritised vulnerable adults or children. They take these decisions at their discretion, which means the constabulary doesn’t routinely prioritise children and vulnerable adults. Custody officers also don’t record all initial risk assessments on the force IT systems, or they record entries that lack detail. And they didn’t always update the risk assessments during the detainee’s detention. With violent detainees, custody officers didn’t always record risk assessments at booking-in or at a later stage during the detention period.

Custody officers routinely take the decision to remove clothing and footwear with cords. This is the constabulary’s position, but this is contrary to paragraph 4.2 of PACE code C 2023 and doesn’t follow APP guidance. This is a change in practice since our last inspection. They don’t record the necessity and justification for removing clothing and footwear in line with the risk assessment. And they don’t record what replacement clothing they offer to detainees. But when anti-rip clothing was provided it was appropriate to the risks and observation levels set, and usually done after a detainee had attempted to harm themselves.

Custody officers mostly set appropriate observation levels for detainees in line with the risks presented. But they don’t always set appropriate level 2 observation levels (intermittent observations with rousal checks every 30 minutes) for all detainees who appear under the influence of alcohol or drugs.

Custody officers sometimes inappropriately lower observation levels within a short period of detention time without updating the risk assessment or recording the rationale. This potentially increases risk of harm to the detainee. Custody officers work together with healthcare professionals (HCPs) on risk assessments. But this collaboration could be improved, particularly for detainees who are dependent on alcohol or drugs, or for those where custody officers lower observation levels quickly.

Custody officers complete care plans to a high standard and write comprehensive and detailed entries on custody records. There were some good examples of them updating these plans during the detention period and recording decisions and rationale.

When custody officers place detainees on level 3 (constant observation by CCTV) or level 4 (physical supervision at close proximity) observations, they use a standard briefing. This is copied onto the custody record with the names/collar numbers of officers doing the monitoring. Officers carrying out these observations told us the custody officer had also given an oral briefing.

When detainees are on level 2 observations detention officers carry out rousing checks appropriately, on time and in line with APP. This is generally by the same detention officer, which provides continuity of care. Detention officers communicate well with detainees and focus on their well-being. They are alert to changes in conditions and record the detail of rousing checks well.

Custody personnel completed comprehensive handovers that cover risks and include updates on each detainee. The handovers are also attended by HCPs and sometimes the liaison and diversion practitioner.

Custody officers explain the cell call bell system to detainees at the time of booking-in. During our observations in suites, we saw detention officers answering calls promptly.

Custody officers visit and speak with all detainees in their care at the start of each shift. Detention officers do their own checks at the start of their shift.

Custody personnel maintain good control of keys. There is a system that records who books keys out and what time they are returned.

The constabulary provides some ongoing training and is rolling out additional training to help personnel understand the ongoing effect of previous trauma on detainees’ mental health. This awareness will help them to support detainees while they are in custody. Custody officers told us they would like more training on healthcare, particularly to help them understand when detainees talk about their medication. They have a good understanding of vulnerability, mental health and neurodivergent conditions and this can help them to identify vulnerability in detainees.

Individual legal rights – detention

Arresting officers give a good account of the arrest and its necessity as required by PACE code G 2012. But custody record entries don’t always reflect how necessity was specific to the arrest.

The booking-in process is thorough and custody officers clearly explain the procedures. They appropriately authorise detention and consider the welfare and needs of vulnerable detainees. We saw a good example of a custody officer explaining the process and providing reassurance to a detainee who had never been in custody before.

Custody officers told us they are confident to refuse detention and will do so if they don’t consider it necessary to detain someone in police custody. The constabulary scrutinises refusals of detention and publishes the outcomes in a monthly custody report.

The constabulary actively considers out-of-court disposal options and is involved in a range of diversion schemes with partner organisations from social care and youth justice. It uses voluntary attendance as an alternative to arrest but was unable to provide any data about how often it uses this. This limits the extent to which it can understand the appropriate use of voluntary attendance. There are enough interview rooms at Thorpe Wood and Parkside for voluntary attendees, so they only need to enter custody for fingerprints or other processes such as taking DNA and photographs.

We saw examples of custody officers proactively monitoring the progress of investigations. This was to make sure detention times were kept to a minimum and check that ongoing grounds for detention remained necessary. This included a case where the custody officer decided to bail a child rather than detain them overnight.

Custody officers review bail conditions with investigating officers and appropriately authorise bail. They clearly explain conditions and restrictions to detainees. In our case audits we found that custody record entries showed detailed rationale for bail decisions and consideration for safeguarding victims, witnesses and detainees. We also saw some good examples of custody officers scrutinising bail conditions and risk management.

The constabulary makes good use of detention time to finalise investigations, or release detainees on bail or under investigation. Where custody officers decide to remand detainees in custody after charge, they usually record this well on custody records.

Custody personnel told us that detainees in custody for immigration offences can sometimes wait a long time to be transferred. Information provided by the constabulary shows that for the year 1 March 2023 to 29 February 2024, immigration detainees spent an average of 23 hours in custody after their immigration papers (IS91) were served.

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. Easy read versions are available for those who need help in understanding them.

These include the right:

• to have someone informed of their arrest;
• to consult a solicitor and access free independent legal advice; and
• to consult the PACE codes of practice.

Detainees can exercise these rights promptly. All suites have enough PACE code C 2023 books and custody officers routinely offer these to detainees during the booking‑in process.

Custody officers know how to provide written translations of documents to detainees as required by annex M of PACE code C. This states that detainees should receive documents and records about custody processes in a language they understand. We saw custody officers handing out written translations of rights and entitlements to detainees who didn’t speak English.

Custody officers use interpreters to make sure they can give detainees their rights in a language they understand. We saw a good example of a custody officer helping to translate information while waiting for an interpreter for an uncommon language. Custody officers ask foreign national detainees (detainees who aren’t British citizens) if they wish to have their embassy informed of their arrest. We saw this throughout our case audits and in observations in suites. Where bilateral agreements are in place, custody officers notify embassies.

When detainees were unfit through alcohol or drugs at the time of booking-in, we saw custody officers providing rights and entitlements as soon as the detainee could understand them.

Legal representatives attend custody in person. They receive a copy of the front sheet of their client’s custody record. There are enough places for detainees to speak with their legal representatives privately. They can also speak with legal representatives privately on the telephone. All suites display posters in different languages to notify detainees of their ongoing right to free independent legal advice. At Parkside there is stencilling inside cells reminding detainees of this right. In our observations in suites, we saw a custody officer exploring the reasons why a detainee waived their right to legal advice. But in our custody record analysis there were no examples of such conversations taking place after a detainee said they didn’t want legal advice.

Custody officers appropriately authorise any decision to hold a detainee incommunicado. When a decision is later taken to reinstate a detainee’s right to have someone told of their arrest, custody officers should inform the detainee. However, in our custody record review we found two cases where there was no record of the detainee being told that this right had been reinstated and that they could have someone informed of their detention.

Some information was displayed at Parkside to inform detainees about their rights under the Protection of Freedoms Act 2012 and how DNA samples are retained and destroyed. But at Thorpe Wood this information wasn’t prominently displayed. Some detention officers we spoke to said that they told detainees this information while taking samples, but others said they didn’t.

DNA samples are stored in freezers that are in good condition and are collected daily. But the freezers aren’t lockable and aren’t in rooms with lockable doors. This potentially undermines the integrity of the samples.

Reviews of detention

Section 40 PACE reviews (periodic reviews of detention) don’t always comply with the requirements of the PACE codes of practice. They aren’t always carried out well enough, or in the best interests of the detainee. We gave the constabulary feedback during our inspection due to the concerns we had, and they took immediate action by briefing custody personnel. We subsequently saw some improvements in the thoroughness of reviews done in person and the standard of recording.

During our inspection we saw reviews carried out in person and these were of a higher standard than what was reflected on custody records. Inspectors covered many of the requirements such as explaining their role and the reasons for authorising ongoing detention. They were respectful, empathic and communicated clearly with detainees.

However, in our custody record analysis and case audits we found the overall standard of reviews was poor. In many cases it wasn’t clear that custody officers had completed a meaningful review. There was no record that detainees were given the opportunity to make representations nor be told that their ongoing detention had been authorised.

The constabulary listed far more sleeping reviews than we would expect. Of the 100 cases we looked at in our custody record analysis, custody officers had carried out 43 while the detainee was asleep. In some cases, it was reasonable not to wake a detainee because they were in a rest period. However, custody officers had carried out some sleeping reviews during the day and outside rest periods. This included when the custody record showed that the detainee was awake around the same time as the review took place, or shortly before or after.

When custody officers carried out sleeping reviews, they rarely informed detainees of the review taking place. This is contrary to PACE code C paragraph 15.7.

Inspectors didn’t contact interpreters by telephone when carrying out reviews of detention for detainees who couldn’t speak English. Instead, they asked for detainees to be informed of the review when an interpreter was available in the custody suite. But we found no record of this happening.

In some cases when reviews were carried out by telephone the inspector didn’t speak with the detainee, as custody personnel were too busy to set up the call. This included reviews for children in custody. When reviewing detention for children and vulnerable adults in custody, inspectors didn’t always consider the specific needs of these individuals.

We found 13 cases with no record of a first PACE review. This included children and vulnerable adults. Some had been in custody for hours after the review was due.

Inspectors record their reviews using standard templates. We found that these were often generic, and confusing or contradictory where the standard text had been left in without removing the words that didn’t apply to the detainees. This made it difficult to be sure that the detainee’s individual circumstances had been considered.

Early on in our inspection we observed a superintendent carry out a section 42 PACE review in person (to extend the period of detention). This was done thoroughly and covered the investigation, detainee welfare and the rationale for authorising continued detention. The superintendent sought representations from the detainee and their legal representative about why they opposed the continued detention. This was all explained clearly to the detainee.

Complaints

The constabulary’s policy provides clear guidance on the complaints process. But not all custody personnel we spoke to knew what to do if a detainee wanted to make a complaint. Some said they would inform an inspector or the custody officer, but others said that complaints wouldn’t be taken in custody.

The constabulary provides some information to detainees about making a complaint, but this isn’t well promoted in the suites. We gave the constabulary feedback during our inspection, and they acted quickly to produce new posters to display and make this information clearer.

In our audits we reviewed a case where an inspector had personally spoken with a detainee who wanted to make a complaint, but we didn’t see any other examples of custody personnel taking complaints. The constabulary collates data relating to complaints about custody, but this doesn’t identify whether the complaint was taken while the detainee was in custody. This means that the constabulary doesn’t fully understand how well this process is working in practice.

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

The custody estate in Cambridgeshire has two full-time designated suites at Parkside and Thorpe Wood, and two contingency suites at Huntingdon and March. The suites at Huntingdon and March aren’t operational and are used when one of the full-time suites closes temporarily. All the suites were constructed during the 1960s and 1970s with some later additions increasing cell capacity. They are dated in design but Thorpe Wood, due to its alterations and adaptions, has the feel of a more modern custody unit. Cambridgeshire Constabulary owns and maintains all the suites.

Cambridgeshire Constabulary has recognised the limitations of its custody estate. It is currently building a new custody unit at Milton in Cambridge to replace Parkside from 2025.

There are potential ligature points in all the suites. These are mainly around some cell bunk vents, cell door frames, and due to the toilet design at Parkside and Thorpe Wood. Potential ligature points also exist in drain covers for showers and exercise yards. During the inspection we gave the constabulary a comprehensive report detailing these and the physical conditions in the suites more generally.

Overall, cleanliness at all four suites is good, with well-maintained cells and communal areas. The cells have natural light, and there is no graffiti in the suites. But the communal areas at Parkside, Huntingdon and March are cramped, particularly the booking-in areas. This restricts the number of detainees who can be booked in, to one at a time, to maintain privacy.

There are no glass-fronted cells to help detainees who are anxious or have claustrophobia and to help manage risk. Other than at Thorpe Wood, most cells are without sinks. But all cells have toilets and there are communal showers and washing facilities at each suite. There is a disabled toilet at Parkside and at March.

Custody personnel should carry out and record daily and weekly safety and maintenance checks of the physical environment as required by APP. But we found that there was a lack of consistency with recorded checks at both Parkside and Thorpe Wood. We were told the constabulary usually completes repairs quickly.

Custody officers and staff can monitor detainees on CCTV in each of the suites. Monitors can’t be seen by those in the communal areas. But officers observing detainees on level 3 constant observations at Parkside and Huntingdon do so in an area where there are distractions. Some areas in the suites aren’t covered by the cameras, which we pointed out to the constabulary. All cells have CCTV, increasing the constabulary’s ability to manage risk, particularly when suites are busy. All suites have notices advising that CCTV is in operation, as required by PACE code C paragraph 3.11. But the constabulary could improve these in the booking-in areas, where it is more difficult for detainees to see these signs.

Custody personnel are aware of emergency evacuation procedures and most officers and staff we spoke to had taken part in evacuation training. There are enough handcuffs and other emergency equipment at suites to evacuate all cells if required.

Use of force

When force is used in custody, officers and staff don’t always manage or record it well enough. But there were some good examples of care provided to detainees and attempts to de-escalate incidents.

We examined custody records and viewed CCTV footage for 23 cases where force was used. In most cases the force was proportionate to the risk or threat posed.

When force is used, the constabulary doesn’t always record the incident well. In some cases we reviewed, custody personnel hadn’t made a record of the use of force at all. In other cases, they had recorded only one incident when multiple incidents had occurred during the detention period. Custody records often lacked detail about what force was used, who was involved, injuries sustained, risks identified, and whether other tactics were considered as per the national decision model.

Custody officers regularly became involved in the application of force rather than having overall supervision or management of the incident.

We saw some good communication, negotiation and de-escalation by officers. In most cases officers showed a good awareness of risks such as acute behavioural disturbance and positional asphyxia. They minimised harm and provided care to detainees by using mattresses and pillows for protection when they used appropriate force in the cells. In one case, officers held a detainee’s head for some time to prevent injury.

Custody officers record when a detainee arrives at custody in handcuffs, but they don’t record the time the handcuffs are removed.

In the CCTV records we viewed, escorting officers generally removed handcuffs from compliant detainees soon after they arrived at custody, and often in the holding area. However, occasionally officers removed handcuffs too soon from volatile detainees, or where it was unclear whether the detainee had been previously searched. In these cases, detainees needed to be restrained using further force including reapplying handcuffs. This risked injury to the detainee and the officers involved, and could have been avoided if the officers had considered all risks prior to the removal of handcuffs.

Where officers used restraints such as leg restraints or spit and bite guards, they had applied these correctly and checked them regularly. However, in nearly a quarter of the cases we reviewed, arresting officers had handcuffed detainees to the front. In some instances, this led to further use of force in custody and increased the risk of injury. Officers using unarmed techniques didn’t always do so effectively, which meant they didn’t have control of the situation. This lack of control led to more officers becoming involved, further use of force to restrain detainees, and an increased risk of injury.

When officers use force on detainees in custody they don’t always submit individual use of force forms as required by National Police Chiefs’ Council guidance. This is despite notices in custody suites reminding them to do so. We asked for use of force forms for the incidents we reviewed but didn’t receive all the forms we were expecting (we expected 120 and received 65). This means when force is used, Cambridgeshire Constabulary can’t always show it is proportionate, justified and necessary.

In line with APP the constabulary now has a process to record when detainees’ own clothing is removed and they are given replacements, and the reasons why. This is positive. But the records don’t align these reasons to the risks posed. For example, custody personnel don’t always record how the decision to exchange a detainee’s clothing relates to the individual risk assessment, or whether they consider other ways to manage this risk (such as appropriate observation levels). In some cases we reviewed, it wasn’t clear that the removal was necessary and justified.

We saw some good examples of custody personnel accurately authorising and recording strip searches. The records clearly displayed the grounds for the search, the officers involved and the result.

When officers carried out strip searches or exchanges of clothing in cells, they attempted to protect detainee dignity by using blankets. But it wasn’t clear if custody personnel had switched off cell CCTV, or blocked the screens from view so they couldn’t be seen by others. In one case, male officers were present when clothing was removed from a female detainee.

During our CCTV review we found some areas of the custody suites not covered by the cameras. We also noticed some camera feeds had no audio, and there were discrepancies in the times shown on different cameras. We notified the constabulary of this, and it took immediate action.

Most custody officers and detention officers are up to date with their officer safety training, and training is planned for those who aren’t. But the tri-force training arrangements can delay the availability of courses.

We referred four cases to the constabulary for consideration and learning. These related to use of PAVA incapacitant spray in cells, unarmed tactics and one case where we had concerns about integrity.

The constabulary scrutinises the decision making and recording of strip searches for adults and children at monthly senior leadership team meetings. This is to make sure the searches are justified, necessary and proportionate. The custody senior leadership team reviews use of force data at its monthly meetings. Cambridgeshire Constabulary carries out some quality assurance on the use of force in custody. But this doesn’t include dip sampling CCTV footage of incidents or reviewing the quality of entries on custody records.

Detainee care

The approach to detainee care is good. Detainees we spoke to were positive about the care provisions and facilities offered and available to them. Custody personnel tell detainees about their entitlements to food and drink, showers, exercise and reading material at the time of booking them in to custody.

There is a good range of food and drink, and this is offered and provided regularly. The constabulary caters for all reasonable dietary requirements. Fresh sandwiches and wraps are delivered to the suites three times per week.

Distraction materials such as foam balls, ear defenders, and colouring books are available in all the suites. We saw these being handed out frequently. There are also e-books for children and a video of what to expect while in custody, but it wasn’t clear how often custody personnel give these out.

The range of reading material is good. Both suites have a good supply of books including foreign language titles. We saw these being offered and detainees with reading materials in their cells. Petty cash is available to buy magazines for children.

Custody personnel offer detainees showers, but this depends on how busy the suite is and whether there are officers available to supervise them. We saw several detainees taking exercise during our observations in the suites. Although the exercise yards aren’t step-free, they do offer some cover for bad weather.

There is a good supply of replacement clothing in the suites, including underwear, socks and footwear in a range of sizes. There is also an adequate supply of towels.

Custody personnel provide detainees with a box of toilet tissue as they enter the cell. Each custody cell also contains a mattress and pillow. The quality and condition of the mattresses across the custody estate is adequate, but many are worn and need replacing. They also receive a blanket and can request a second one if required.

Safeguarding children and vulnerable people

Custody personnel recognise the importance of safeguarding children and vulnerable adults while in custody and on their release. They have a good awareness of a person’s vulnerability and have had some training around this.

Where necessary, investigating officers complete safeguarding forms for children and vulnerable adults. They discuss safeguarding concerns with custody officers to make sure that any risks of harm are minimised both inside and outside custody.

The constabulary has recently introduced a process for children who are brought into custody. This requires custody personnel to make immediate contact with children’s social services and the multi-agency safeguarding hub, to exchange risk and safeguarding information. This process is referred to as the golden hour process for dealing with children in custody. The constabulary aims to get the best outcomes for detained children through having early contact with safeguarding organisations. This is a new process and we saw custody personnel completing the relevant checks, which is positive. But in one of the cases we audited, custody officers didn’t appear to consider information received from social services for the risk assessment.

The constabulary generally refers children and vulnerable adults to liaison and diversion services for assessment and support. This provides additional opportunities for safeguarding.

Girls under 18 held in custody are required to have a female member of personnel assigned to safeguard and monitor their welfare while in custody, as per the Children’s and Young Persons Act 1933. But in the cases we examined, it wasn’t clear if this had happened as it wasn’t recorded.

From our observations in suites, we saw that custody officers arrange for children to get home safely after leaving custody. But they didn’t always record these considerations in custody records.

Appropriate adults

In most cases AAs attend custody promptly, but some children or vulnerable adults wait a long time for an AA.

In the first instance, custody officers consider parents, family members or carers to act as AAs. Where they aren’t available or are unsuitable, the constabulary has arrangements with TAAS to provide AAs. This service operates on 24 hours a day, 7 days a week for children and vulnerable adults and covers both suites.

Custody officers are responsible for arranging AAs. They should contact the AA within 60 minutes of detention being authorised, or as soon as practicable if the need for an AA has been identified after booking-in. The constabulary expects that TAAS AAs will arrive within two hours of being requested, but this doesn’t always happen. From our observations in the suites, we found that AAs arrived quickly in some cases, but other detainees waited a long time. In one case we noted that TAAS couldn’t provide an AA at night due to a lack of availability.

The constabulary told us it has a good working relationship with TAAS. There is an informal escalation procedure to contact the TAAS manager when it is difficult to obtain an AA. We were told that this usually results in an AA being provided.

AAs should attend custody for rights and entitlements, fingerprints and DNA, and for interviews. We found that AAs provide support for detainees throughout the custody process which is positive. And we saw that AAs were present during reviews in some cases.

Where a family member or friend acts as an AA, custody officers explain what is expected of them in the role of AA. They also explain to the detainee what the role of an AA is.

Custody personnel don’t consistently or clearly record AA contact and arrival times, and the relationship of the AA to the detainee, on custody records. This makes it difficult for the constabulary to assess how well it meets detainee needs in this area. The constabulary relies on TAAS to provide this data and discusses performance with the service at quarterly meetings. But TAAS only assesses its own data and doesn’t include how long it takes for parents or carers to attend and act as AAs. This means the constabulary doesn’t have the full picture when it comes to AA provision.

During our last inspection, we issued an area for improvement related to this. We said that the constabulary should how well it assess effectiveness of TAAS through robust monitoring arrangements. And we said that it should make sure custody records consistently record all relevant information to make this possible. This hasn’t been achieved.

Children

There is a good focus among frontline officers and custody personnel on diverting children away from custody where possible. The constabulary told us it uses voluntary attendance and out-of-court disposals to keep children out of custody. It has a ‘young persons’ policy to support this diversion process. It also has informal processes where arresting officers can phone custody officers for guidance before bringing a child to custody. Custody officers told us they would feel confident to refuse detention for a child who could be dealt with outside custody.

Custody officers generally place children in cells nearest the booking-in desk, and in cells that have chalkboards that they can write on. There is a discrete booking-in facility at Thorpe Wood that can be used to book in children and vulnerable adults where necessary.

Custody personnel provide a good level of care to children in custody. There are distraction materials at both suites, such as foam footballs and colouring books. We saw these being offered and used during our inspection. Children can spend time out of their cell in the exercise yard, or with their appropriate adult, which is positive.

The constabulary’s policy expects children to be prioritised for booking-in. During our observation in the suites, there was little evidence of this happening, although some custody officers checked to see who was waiting to be booked in. In our children’s audits, three children waited between 1 hour 24 minutes and nearly 2 hours to be booked in. In these cases, the custody record didn’t reflect if custody officers had considered prioritising them.

Cambridgeshire Constabulary expects custody personnel to deal quickly with children brought into custody. We saw that custody officers were proactive in overseeing the progression of investigation to keep children’s time in custody to a minimum. And we observed children being bailed or released under investigation to try and keep their time in custody as short as possible.

But some children spend longer in custody when compared with adults. The constabulary has some understanding of this and told us reasons for this include additional safeguarding measures, the complexity of some cases and the nature of the investigations. The constabulary holds regular meetings to discuss acute and complex cases.

Where children are charged and remanded into custody, they should be moved to alternative accommodation arranged through the local authority while they are waiting to appear in court. Despite the constabulary’s work with the local authority to improve the provision of alternative accommodation, progress has been limited since our last inspection. The senior leadership team scrutinises the overnight detention of children, and a custody monthly report includes details of this.

Although the constabulary requests alternative accommodation, the local authority doesn’t move many children. In the year up to 29 February 2024, information provided by the constabulary shows that 48 children were charged and refused bail. Of these, 33 requests were made to the local authority for accommodation, both secure and non-secure, and two children were moved. This is a poor outcome for children. But the recently introduced golden hour checks are intended to start conversations early on in a child’s detention, in the hope of maximising the chances of obtaining alternative accommodation for remanded children.

Healthcare

Mitie Care & Custody is contracted to provide physical healthcare support to detainees and carry out forensic testing in custody. HCPs are allocated to both custody suites and provide healthcare cover on 24 hours a day, 7 days a week. Senior HCPs are available daily to support the service.

Mitie took over the contract at the end of February 2024, five weeks earlier than intended. The contract covers three police force areas. Staffing difficulties across the whole contract have affected staffing at both Cambridgeshire suites, as HCPs have at times had to work across all three forces rather than being based in Cambridgeshire. As a result, and due to the high number of people being detained, not all detainees have been seen within contractual timeframes of 60 minutes. HCPs prioritise work based on clinical need. Mitie has an ongoing recruitment process to fill HCP vacancies.

Partnership working between the constabulary and healthcare partners is good. Governance processes provide a strategic overview and united approach to monitoring safety, quality and performance of health services. The constabulary and health providers meet regularly, and this collaborative working helps to improve services and outcomes for detainees.

Not all HCPs are up to date with mandatory training due to it being a new contract. Staff have been given time by Mitie to complete this. Clinical supervision is available to all staff. Although this has initially been informal, Mitie has plans to formalise this in the future. Staff we spoke with felt well supported by their employers.

Each custody suite has a medical room which is solely used by HCPs. Medical rooms are well equipped and HCPs check emergency equipment frequently, as required by Mitie. But despite the healthcare provider carrying out regular checks, infection control standards need to be improved.

Healthcare staff have access to interpreters for detainees whose first language isn’t English.

Not all force policies and procedures are current which means that officers can’t be certain they are carrying out their work in line with up-to-date guidance and standards. For example, the Joint Protocol for the Management of Acute Behavioural Disturbance, Positional (Restraint) Asphyxia in Police Custody, Cambridgeshire Custody Administering of Medication Procedures and Custody Mental Health Assessment Procedure, all relate to previous providers. We were told that the constabulary is currently revising these.

The provider reports incidents through their electronic reporting systems. They investigate incidents and share learning with personnel through meetings and supervision.

A confidential complaints process is in place. This is an improvement since our last inspection. But this process isn’t advertised to detainees and should be more visible.

Physical health

Experienced and competent HCPs provide treatment for detainees. Where required, HCPs also have access to more senior staff for clinical advice, including out of hours.

Custody personnel we spoke with acknowledged 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 to make sure any response is timely.

With the detainee’s consent HCPs carry out assessments of physical and mental health (including the detainee’s mental capacity). This consent also includes HCPs accessing a summary of the detainee’s community health records, including any prescribed medication.

HCPs complete a record of their assessment and treatment on their own electronic clinical record. They also have access to the force’s IT systems and record a summary of this information on the detainee’s custody log. This makes sure that custody personnel and liaison and diversion staff are aware of the detainee’s healthcare needs. HCPs contribute to decisions regarding risk and fitness to detain, interview or release.

HCPs take intimate samples when needed. This is carried out in the same medical room when it should take place in a separate room. But the room is appropriately cleaned before and after examinations. An officer is present, but dignity curtains are in place to provide privacy for the detainee.

Mental health

NHS England commissions the liaison and diversion service via Cambridgeshire and Peterborough NHS Foundation Trust. This service covers all types of vulnerabilities, including social needs and health. Partnership arrangements are good with effective oversight from NHS commissioners.

Practitioners from liaison and diversion are based in both suites seven days per week between 8am and 8pm. Dedicated and skilled qualified nurses provide good support to vulnerable detainees in custody. Support and onward referral are available for detainees with mental health and drug and alcohol issues, as well as housing and social problems.

Liaison and diversion staff are up to date with mandatory training which supports them in their roles, such as safeguarding adults and children. They also have an annual appraisal of their performance.

Custody personnel can make referrals to the liaison and diversion service and the practitioners are proactive in visiting detainees to inform them about the service. They carry out assessments promptly. There is also a process for custody personnel and HCPs to make referrals to the service out of hours. Liaison and diversion practitioners review the referrals the following day and take appropriate action.

The liaison and diversion service also offers support and information for detainees post-release. Custody personnel provide all detainees with the liaison and diversion service leaflet prior to leaving custody, which contains key information about services and where they can get help, such as food banks and sexual health services.

All members of the liaison and diversion team can access detainees’ community mental health records with their consent. When they complete assessments in custody, liaison and diversion staff update their patient record system. Liaison and diversion staff can also access the force’s custody IT system to record information.

Communication between liaison and diversion team members and custody personnel is good. This includes, on weekdays, a daily meeting between the liaison and diversion service, custody officers and the substance misuse provider to discuss detainees who are in custody. In addition, they verbally hand over or communicate relevant information about detainees to custody personnel. Custody personnel spoke highly of the service and how they worked jointly together to help improve outcomes for detainees.

One local authority covers the constabulary’s geographical area. There is a process in place for when a doctor is needed to make an assessment under the Mental Health Act 1983, both during the day and out of hours. But doctor availability is minimal after midnight.

The constabulary is proactive in identifying, supporting and managing people with mental health concerns in custody and in the community. This includes the use of mental health practitioners in two patrol cars and in the control room, to support frontline police officers who are called to incidents involving people with mental health concerns.

Custody isn’t used as a place of safety under section 136 of the Mental Health Act, except under exceptional circumstances. There is only one section 136 suite, resulting in it often being in use. This means that officers have to take detainees to the accident and emergency department.

There are good working relationships between the force mental health lead and mental health providers, as well as with partners such as the Approved Mental Health Professionals service, section 136 suite managers, hospitals, and the social services’ Emergency Duty Team. The focus is on working together to resolve and manage any difficulties. This includes a weekly meeting looking at incidents to see what learning could be taken and shared, and how systems could be improved. Working together in this way has led to the reduction of the use of section 136 of the Mental Health Act in and out of custody.

Substance misuse

HCPs assess and provide treatment for detainees withdrawing from drugs and alcohol while in custody. They carry out assessments using nationally recognised clinical tools to inform decision-making and to monitor detainees’ treatment needs. HCPs administer medicines to relieve symptoms of withdrawal when clinically indicated. There are appropriate patient group directions (PGDs) to support this.

PGDs offer a framework that lets some registered HCPs administer specific medicines to particular groups of patients. Crucially, PGDs allow this to be done without them seeing a prescriber. The PGDs help HCPs make decisions on various health issues, including acute withdrawal from alcohol and drugs, antibiotics, and pain relief. If detainees are already in receipt of opiate substitution treatment in the community, this can be provided while they are in custody. Subject to verification of a supervised community prescription by an HCP, police officers can collect methadone from the detainee’s pharmacy, and HCPs administer this.

Liaison and diversion practitioners refer any detainees who require support from drug and alcohol services in the community and will support them in attending appointments. Drug testing on arrest is in place and where relevant detainees are referred to appropriate services.

Medicines management

HCPs provide medicines for detainees following assessment and in line with an extensive range of PGDs provided by Mitie. Custody personnel can provide nicotine replacement lozenges on request. They also have access to paracetamol and inhalers and can give these to detainees following consultation with an HCP. But custody personnel don’t record this consistently. Only one suite keeps a record of stored medication, and not all HCPs document when they give advice to officers on their clinical records.

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, including controlled drugs. They receive regular training.

Regular audits of medicines help 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 with their property and, with support from HCPs, give these to detainees at the scheduled times.

When detainees go to court, their own medicines are transported with them. Where possible, detainees who don’t have their own supply of medicines are given any required medicine before leaving custody to go to court. But there is no provision to make sure such medicines are 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 personnel focus on helping all detainees get home safely and especially children and vulnerable adults. Where necessary or appropriate, they give detainees bus or rail tickets, or police vehicles are used to transport them home.

However, custody officers don’t always complete and record a thorough pre-release risk assessment while the detainee is in their presence. They don’t always consider or record any risks from the initial risk assessment when the detainee entered custody, or concerns that may have become apparent in custody or have been identified by HCPs or the liaison and diversion service.

Custody officers explain bail conditions, or the process of being released under investigation, well. They fully explain the consequences of breaching bail conditions to detainees, or the offences that those released under investigation may possibly commit if they interfere with victims or witnesses while the investigation is ongoing.

There is good support agency information available, and custody personnel offer leaflets to most detainees on release.

Custody detention officers complete digital person escort records and arrange transport for detainees who are attending court, or for those recalled to prison. They complete these records well and include relevant risk, health and medication information. Custody officers check the records but, other than this, don’t have much involvement with, or oversight of, the release of detainees to court. Custody officers don’t routinely speak with detainees leaving custody to complete a pre-release risk assessment with them. These practices don’t follow APP guidance.

Courts

When detainees are remanded, they aren’t always transferred promptly to the next available court. The organisation that is contracted to escort detainees to court isn’t consistent with its attendance times and sometimes attends late. Detainees appear before a local court in person, but sometimes the courts don’t have the capacity to accept all remanded detainees at the same time. This results in some detainees being transferred later in the day or attending the court through video link facilities. This lengthens their stay in police custody and is a poor outcome for detainees.

Detainees remanded or arrested on warrant during the day are sometimes able to appear before the court later the same day. We were told that there was some flexibility between court and custody personnel to achieve this as the constabulary uses police vehicles to transport detainees, and therefore minimise a detainees’ time in police custody.

Section 6. Summary of areas for improvement

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

• Ian Smith: HMICFRS inspection lead
• Nicola Duffy: HMICFRS inspection officer
• Justine Wilson: HMICFRS inspection officer
• Andrew Reed: HMICFRS inspection officer
• Emmanuelle Versmessen: HMICFRS inspection officer
• Sarah Hamilton: HMICFRS inspection officer
• Catherine Raycraft: CQC inspector
• Dayni Johnson: CQC inspector

Fact page

Note: Data supplied by the force.

Force

Cambridgeshire Constabulary

Chief constable

Nick Dean

Police and crime commissioner

Darryl Preston

Geographical area

Eastern

Date of last police custody inspection

7-18 August 2017

Custody suites

Main: Thorpe Wood (26 cells), Parkside (11 cells)
Fallback: March (12 cells), Huntingdon (10 cells)

Annual custody throughput

12 months to the end of February 2024: 9,830

Custody staffing

26 custody officers
24 detention officers
One custody prevention and one Drug Testing on Arrest co-ordinator
One quality assurance and policy officer

Health service provider

Mitie Care & Custody

Back to publication

Report on an inspection visit to police custody suites in Cambridgeshire Constabulary