Report on an inspection visit to police custody suites in Thames Valley Police

Summary

This report describes our findings following an inspection of Thames Valley Police custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and the Care Quality Commission (CQC) in July 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 force improve, we have made one recommendation to it and its police and crime commissioner. This addresses our main cause of concern.

We have also highlighted a further 15 areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and working with partners

Thames Valley Police has clear governance arrangements for the provision of custody services and there are strategic and operational meetings to oversee and manage custody.

Senior leaders are actively involved in seeking to improve custody services. However, the force hasn’t made enough improvement in some of the areas where we identified concerns in our last inspection. For example, the quality assurance processes for custody records aren’t robust enough, and the force is still developing processes to scrutinise use of force incidents. Scrutiny of custody services was a cause of concern in our previous inspection and the overall leadership and scrutiny of custody remains a cause of concern.

The force has full-time custody personnel to provide custody services. Initial training for custody personnel is comprehensive and follows the nationally approved course developed by the College of Policing. The force also provides ongoing training five times per year.

We found that, due to the demand and workload, custody personnel sometimes struggled to carry out their role and meet detainees’ needs. When there was only one custody officer on duty, some detainees waited a long time to be booked in.

The force manages custody services across six operational suites at Abingdon, Aylesbury, Banbury, Loddon Valley, Maidenhead and Milton Keynes. The physical condition of the suites varies. All suites have potential ligature points and some of these were the same as we found in our last inspection. Not all personnel were initially aware of these, but, by the end of the inspection, the force had provided an update to make personnel aware of the potential ligature points we had found.

The force has adopted the College of Policing’s authorised professional practice (APP) guidance, but not all personnel know the guidance or consistently follow it. And the force doesn’t always consistently follow the Police and Criminal Evidence Act 1984 (PACE) codes of practice. This includes practices such as authorising detention in van docks and not recording the grounds with the detainee present, and how some reviews of detention are carried out.

The force collects and monitors a range of performance information which is discussed at the various meetings that oversee custody performance.

The quality assurance arrangements to assess how well custody services are provided aren’t robust enough. The force dip samples custody records, but this process hasn’t identified some of the concerns we found during our inspection. And some areas, such as reviews of detention, aren’t dip sampled. We found there has been little senior leadership focus on improving the standard and quality of custody records. This contributes to our cause of concern about leadership.

Use of force incidents are monitored at custody governance and performance meetings. But, overall, the governance and oversight of the use of force in custody isn’t good enough. This means that Thames Valley Police can’t always assure itself or the public that when force is used in custody it is necessary, justified and proportionate. This hasn’t improved enough since our last inspection and forms part of our cause of concern about leadership and accountability.

We reviewed 20 use of force incidents. We found that when detainees were under restraint for long periods using handcuffs, spit hoods or leg restraints, custody officers didn’t always supervise incidents to make sure the ongoing force was necessary and proportionate. We also found that use of force incidents aren’t always recorded in enough detail on custody records. And not all police officers complete the required forms when they use force in custody. We referred four cases to the force to review.

The force understands its responsibilities under the public sector equality duty. But it doesn’t collect data to assess if there are disproportionate outcomes for detainees. Therefore it lacks strategic oversight in this area.

The force is open to external scrutiny. Independent custody visitors (ICVs) visit suites regularly and have a good working relationship with the force.

The force has a priority to divert children and vulnerable adults away from custody and the criminal justice system. It works with its local authorities to review cases where children are remanded in police custody after charge. But the lack of available alternative accommodation means few children are moved as they should be.

The force and its partners have a strong focus on reducing reoffending by identifying vulnerability and making interventions to improve health, social care and criminal justice outcomes. There is a proactive approach to sharing information with partner agencies who can provide support. For example, there is a referral service for women who offend, which resulted in a high number of referrals to support agencies over a 12-month period.

The force works with mental health services at a senior manager level to try and improve the outcomes for people who need this support. But it continues to face significant challenges when dealing with people with mental health conditions, including long waits for assessments.

There is a practice in the force where some people who are detained under section 136 of the Mental Health Act 1983 while in custody are released from the custody suite and detained in other parts of police stations while they wait for an assessment. This may be well intentioned (for example, to avoid long waits at hospital accident and emergency departments) but it doesn’t follow Mental Health Act legislation or APP guidance.

Pre-custody – first point of contact

Frontline officers have a good understanding of how a person may be vulnerable and they take this into account when deciding whether to arrest or take other action at incidents.

Officers told us the information they receive from radio operators (also known as call handlers) in the force’s control room to help them deal with incidents isn’t as good as it could be. They also said they don’t always receive the information they need at the time.

Officers appropriately explore alternatives to custody. This includes practical solutions such as taking children back home to their parents or other family members and dealing with the incident there or using options such as voluntary interviews.

Frontline officers attending incidents involving people with mental health conditions receive limited advice and help from mental health professionals. The force operates a street triage car staffed by a mental health professional and a police officer, but the hours of operation are inconsistent, and this help isn’t always available when needed.

Officers don’t use police custody as a place of safety for people detained under section 136 in a public place. But they often face long waits with detainees for ambulances to arrive, or to access a health-based place of safety. This is a poor outcome for those in mental health crisis and an inefficient use of police officer time.

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

Respect

Custody personnel treat detainees with respect and dignity. They inform detainees that there is CCTV operating in the suites and cells.

Facilities in the suites can make it hard to maintain privacy at the booking-in desks during busy times. We also had concerns that some showers don’t offer sufficient privacy and maintain detainee dignity while detention officers are monitoring them for safety reasons.

Meeting individual and diverse needs

Custody personnel understand how to meet the needs of detainees from protected or minority groups and generally do their best to meet these needs. The force responds well to the needs of female detainees and offers a female custody personnel member as a point of contact.

There is some provision at all suites to meet the needs of people with disabilities but there are few adaptations in the cells. The force is building new custody suites and told us that these will better cater for diverse needs.

The force has installed TV monitors in the holding areas where detainees wait to be booked into custody to provide information to those who may need it.

There is a suitable range of religious items at all suites covering some of the major religions, but these materials weren’t always stored appropriately.

Risk assessments

Custody officers generally make appropriate risk assessments when detainees are booked into custody. But these weren’t consistently well recorded.

During busy periods some detainees wait a long time to be booked into custody. This can increase the risk to detainees and officers. Custody officers told us that they assess and prioritise booking-in detainees. We found some evidence of this during our inspection, but this didn’t appear to be standard or consistent practice at all suites.

Positively, custody officers make use of level 3 or level 4 constant observations for detainees at risk of self-harm, rather than placing them in anti-rip clothing. They provide thorough briefings to officers tasked to carry out these observations.

In our case audits we saw that custody officers were appropriately setting observation levels at level 1. But they were supplementing this with a requirement for detention officers to monitor the detainee on the back-office CCTV. This added precaution doesn’t fall within one of the specified risk management levels in APP guidance. It lacks clarity over what is expected and the rationale for managing the risk.

Custody officers only remove a detainee’s clothing following an individual risk assessment. But footwear is routinely removed.

When detainees are placed on level 2 observations and require rousing, detention officers carry out these checks appropriately and make accurate records.

In general, detention officers carry out cell checks on time and the same officer provides continuity. The checks are carried out well in person but some of the custody record entries are too generic to be meaningful.

Handovers between shifts are carried out to a good standard and in an area where they can be recorded on CCTV. This has improved since our last inspection.

All detention officers carry anti-ligature knives but not all custody officers carry these.

Individual rights

Custody officers generally make appropriate decisions to authorise detention, but they don’t always record the grounds while the detainee is present. This is due to a practice at some suites of speaking to detainees in the van dock holding areas before they enter the custody suite.

Inspectors carry out a review when children are detained so they can satisfy themselves that detention is necessary and check that all relevant actions are underway. This is positive.

The force makes appropriate use of bail or the procedure to release detainees under investigation. Decisions to remand detainees post-charge are recorded on the custody records but not always in enough detail.

Custody officers clearly explain to detainees their rights and entitlements during booking-in and they make sure detainees can exercise these rights promptly. There are enough PACE code C books, but these aren’t the latest version. Detainees can speak with their legal representative in private in person and on the telephone.

Notices outlining how detainees can make a complaint are displayed at all custody suites. But the force could do more to assure itself that complaints are taken while detainees are in custody where this is requested.

Reviews of detention

Reviews of detention for detainees aren’t always carried out in the best interests of detainees and don’t always comply with PACE and its codes of practice.

During our observations in suites, we regularly saw PACE reviews being carried out well by inspectors in person and using the video live link system. But in our case audits we found that some records were poor. These were written in a generic way with little text that was personalised to the individual detainee.

Inspectors generally carried out sleeping reviews only during recognised rest periods. But, when a review of detention takes place while a detainee is asleep, detainees aren’t always informed of the review at the earliest opportunity.

In the custody cell – safeguarding and healthcare

Physical conditions

Due to the age and design of the buildings, the general condition of the suites varies. The suites are mostly well-maintained but there were differences in the overall cleanliness.

Custody personnel at Milton Keynes use the designated holding rooms inside the suite for detainees waiting to be booked in. At other suites, detainees wait outside custody in van docks that the force has adapted for this purpose. However, these areas aren’t fully secure and some lead onto car parks or public areas.

There is no exercise yard at Loddon Valley following a decision to turn the previous space into a large storeroom. The lack of this facility can result in poor outcomes for detainees who are in custody for a long period of time.

Custody personnel we spoke to were aware of emergency evacuation procedures. But few had taken part in a physical evacuation in the past year to make sure they can carry out the procedures in practice.

Use of force

We reviewed 20 cases where force was used in custody. In all these cases, we examined custody records and viewed CCTV footage.

In most cases, the force was proportionate to the risk or threat posed. Officers were patient and generally respectful towards detainees.

In most cases, officers controlled violent detainees appropriately and safely using unarmed tactics and restraint equipment (handcuffs, spit hoods or leg restraints) as necessary. But they didn’t always apply handcuffs properly or do enough to maintain control of detainees.

Custody officers generally make a record of use of force incidents in custody but didn’t always record enough detail. The force told us that they had identified opportunities to improve these processes.

Some detainees spend too long in restraints while waiting to be booked into custody. This increased the risk of harm to detainees and officers and custody officers didn’t review the ongoing necessity for the use of restraint equipment.

Most strip searches carried out under section 54 PACE 1984 to search for concealed items were appropriately authorised, recorded and conducted adequately, although some authorities lacked sufficient information. Custody personnel showed a caring attitude towards detainees when carrying out strip searches and paid good attention to maintaining detainee dignity.

The force gives good scrutiny to incidents where children are strip searched but doesn’t scrutinise searches of adults.

Detainee care

The force provides a reasonable level of care to detainees and custody personnel show a caring attitude.

Custody officers tell detainees about the provisions available to them and detainees were offered showers before attending court.

There is an adequate range of food and drink, and the force caters for most dietary and cultural requirements. All suites have distraction materials available. All suites have a limited range of reading materials although there is a better supply at Loddon Valley. Foreign language titles and reading material for children were limited in most suites.

There is a good supply of replacement clothing, pillows and mattresses.

Safeguarding children and vulnerable people

The force works with its partner organisations to improve safeguarding outcomes for children and vulnerable adults.

Custody personnel take account of safeguarding concerns and the needs of children and vulnerable adults, but this isn’t always reflected in custody records.

Custody officers routinely make referrals to the liaison and diversion (L&D) team and the healthcare professional (HCP) for all children detained in custody, and in our case audits we found that children were seen promptly.

Appropriate adults

Custody personnel make prompt requests for appropriate adults (AAs) to attend custody, but there are sometimes delays in them attending. Due to the statutory arrangements with children’s social care, the service is better for children than it is for vulnerable adults. The force measures the time that AAs attend custody after the request is made.

We saw that custody officers actively involved AAs in the custody process. Where this involved family members, the custody officer provided information about the role of the AA.

Positively, it is common practice in the force for children to spend time in separate rooms in custody with their AA, rather than in a cell.

Children

The force is clear that children should be arrested only when necessary and works well with its youth justice partners to divert children away from custody. It has a series of processes to scrutinise cases where children are in police detention.

When children were arrested it was generally for relatively serious offences. Records didn’t always show the same level of considerations that we saw during our observations.

Custody personnel act in the best interests of children to safeguard their welfare. All girls under 18 are allocated a female carer and custody officers made a record of this.

We found children were dealt with more quickly than adults. Custody officers and PACE inspectors followed up on the progress of investigations to minimise the time children spend in detention. Where there were delays this was usually due to the lack of AA availability.

However, in our case audits we found that there was little rationale recorded when children were detained overnight in custody (pre and post charge), even if the circumstances seemed appropriate. We gave the force feedback on these cases.

Healthcare

Mountain Healthcare Limited (MHL) provides physical healthcare services for detainees 24 hours a day, 7 days a week. Competent HCPs provide prompt clinical assessment and treatment to detainees.

Clinical rooms are tidy and well-equipped and generally comply with infection prevention and control guidelines. Emergency equipment is available if HCPs need to respond to an emergency. However, not all clinical rooms have privacy screens. Where they are available, they aren’t consistently used to maintain detainee dignity during clinical examinations.

HCPs obtain detainees’ consent to carry out assessments. They also contribute to decisions about risk, such as fitness to detain, and interview. They see detainees in private unless the risk assessment indicates otherwise.

L&D teams provide a comprehensive service across the force during their hours of operation and are based at most custody suites. The service includes support for detainees with substance misuse needs.

However, there is no resource or funding for the team to follow up on referrals made outside their working hours. The youth services team follow up any referrals for detainees under the age of 18.

The force and MHL have taken steps to improve the outcomes for detainees who need access to prescribed opiate substitution medication while in custody.

The force doesn’t provide nicotine replacement therapy for detainees, which is poor.

Release and transfer from custody

Custody officers generally make sure detainees are released safely. But pre-release risk assessments (PRRAs) don’t always contain enough detail to show they have identified the potential risks when detainees leave custody.

However, we found that the completion of PRRAs was more thorough and personalised in person than indicated on custody record entries.

On release, custody personnel provide an information leaflet to detainees about the available support services.

When detainees are arrested for certain sex offences custody officers make sure that enhanced PRRAs are carried out.

Detention officers complete digital person escort records (d-PERS) before detainees are transferred to court. Custody officers check these for accuracy before signing them off.

Positively, custody officers lead the handover to the force’s transport contractor, Serco. They provide an update on detainee risks, including any medical concerns. We saw custody officers speaking personally with detainees to check on their welfare before releasing them, although they didn’t always do this in private.

But there are sometimes delays in taking detainees to court. The force is working with Serco to improve this situation.

Cause of concern and recommendation

Introduction

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

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

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

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

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

The expectations are grouped under five inspection areas:

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

The inspections also assess compliance with 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 Thames Valley Police, we analysed a sample of 100 records. The methodology for our inspection is set out in full at Appendix I.

Terminology in this report

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

Section 1. Leadership, accountability and working with partners

Expected outcomes: Leadership, accountability and working with partners

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

Leadership

Thames Valley Police has clear governance arrangements for the provision of custody services. An assistant chief constable has overall responsibility for custody, with a chief superintendent as head of criminal justice. In April 2024, the force introduced new posts to enhance the leadership. A superintendent and two chief inspectors are now directly responsible for the operational running of custody.

The force has strategic and operational meetings to oversee and manage custody services. These include:

• a custody strategy group, chaired by the assistant chief constable, to provide strategic oversight and review matters referred from other custody meetings;
• a custody performance board that examines custody matters in detail, such as cell occupancy levels, cases of children in police detention and strip searching;
• custody management meetings that have oversight of management and risk; and
• meetings with local authority partners to discuss cases of children in custody.

Since our last inspection, the force has improved its governance structures. We found that senior leaders are now actively involved in improving custody services. The force has also recognised the need to update and improve its custody estate. It is managing this through a project called Custody 2030 which includes plans to rebuild the Maidenhead suite and renovate the Loddon Valley suite.

However, the force hasn’t made enough improvement in some of the areas where we identified concerns in our last inspection. For example, the quality assurance processes for custody records aren’t robust enough and the force is still developing processes to scrutinise use of force incidents. Scrutiny of custody services was one of the causes of concern in our previous inspection and it remains a cause of concern.

Force information shows arrests have risen over the past two years and, as a result, the demand for custody services has increased. The force continues to review how many custody personnel and suites are required. This means it can assess how well it can operate and any effect on detainees and personnel. But the force hasn’t yet made changes to meet the increased demand and make sure it provides custody services effectively, safely and efficiently.

Two chief inspectors are responsible for the day-to-day management of custody. They are supported by full-time custody personnel: 7 inspectors, 82 custody officers and 150 detention officers.

But at the time of our inspection, only 131 detention officers were in post due to vacancies. Frontline police officers working overtime cover detention officer shortages, and the force has provided some training for the police constables carrying out this role. But this is limited and means they can’t carry out the full range of duties such as taking fingerprints from detainees. This places additional work on the other detention officers.

We found custody personnel were stretched at times and weren’t always able to carry out all the duties expected of them or meet detainees’ needs. For example, by arranging for detainees to shower or exercise, or recording when they offer food or drink.

Some detainees spent a long time in the van dock holding areas waiting to be booked into custody. This was particularly the case when there was only one custody officer on duty. Some personnel told us they felt overwhelmed due to their workload.

The force manages custody services across six operational suites at Abingdon, Aylesbury, Banbury, Loddon Valley, Maidenhead and Milton Keynes. There is also a contingency suite at High Wycombe that can be used if one of the other suites has to close.

All six operational custody suites are dated. They were built in the 1970s and 1980s and have since been extended. The suite at Abingdon is funded by a private finance initiative contract. Thames Valley Police owns the other five suites and is responsible for maintaining the buildings.

The physical condition of the suites varies. Many communal areas are reasonably well maintained, although some cells were dirty and the toilets in the cells at Loddon Valley, Maidenhead and Milton Keynes were badly stained.

All suites have potential ligature points. During our inspection we gave the force a report of physical conditions and it started to address some of the concerns raised. However, we found many of the same potential ligature points that we identified in our last inspection, and there had been little action to mitigate the risk they pose. Personnel we spoke to weren’t aware of most of the ligature points or what they should do to minimise the risks. By the end of the inspection, the force had made personnel aware of these potential ligature points.

Initial training for custody personnel is comprehensive and follows the nationally approved course developed by the College of Policing. All personnel have a period of shadowing and workplace assessment with more experienced colleagues before carrying out their duties independently. The force provides ongoing training five times a year and one day is used for mandatory training such as first aid training and requalification. In the last year, other training topics have included mental health and neurodiversity awareness. The force has developed and run joint training with its healthcare provider, which is positive.

The force has adopted the College of Policing’s APP guidance, but not all personnel know the guidance or consistently follow it. For example, personnel routinely remove shoes from detainees without carrying out and recording an individual risk assessment. And not all custody officers carry anti-ligature knives.

The force doesn’t always consistently follow PACE and its codes of practice. This includes practices such as authorising detention in van docks without recording the grounds with the detainee present as required by paragraph 3.4 of PACE code C. This may artificially improve performance data relating to waiting times as it may appear that the detainee is in the custody suite when they are still waiting outside. This is unacceptable.

Inspectors don’t always follow section 15 of PACE code C when carrying out reviews of detention, including how these are recorded.

Positively, the force does make sure that girls under 18 are assigned a female personnel member to oversee their care, as required by the Children and Young Persons Act 1933. This level of care is also offered to adult female detainees.

The force has processes to report and investigate any adverse incidents in custody. Custody managers share learning at strategic meetings and by email.

Since our last inspection there have been two deaths in Thames Valley Police custody, and two deaths following release from custody. The Independent Office for Police Conduct has investigated these deaths.

Accountability

The force collects and monitors a range of performance information. This includes:

• the number of detainees entering custody;
• detention times;
• refused detentions;
• cases relating to children in custody;
• numbers detained under section 136 of the Mental Health Act 1983 in custody; and
• strip searches.

The force collates this information into a monthly performance report and discusses it at the meetings that oversee custody performance. The force also monitors AA attendance times and how long detainees wait in custody for an assessment under the Mental Health Act. This is better than we normally find.

The quality assurance arrangements to assess how well custody services are provided aren’t robust enough. The force dip samples custody records, but this process hasn’t identified some of the concerns we found during our inspection.

For example, the force is inconsistent when assessing how well it is performing in areas such as risk assessments and detainee care. And it doesn’t dip sample reviews of detention. This means that it isn’t identifying areas that could be improved, such as the lack of detailed rationale for decisions to remove a detainee’s clothing or shoes when carrying out risk assessments.

The use of standardised pre-populated text often leads to confusing, contradictory and, sometimes, misleading entries on custody records. This was particularly the case for some reviews of detention and general cell visits. We found there has been little senior leadership focus on improving the standard and quality of custody records. This contributes to our cause of concern about leadership and accountability.

Use of force incidents are monitored at custody governance and performance meetings. But, overall, the governance and oversight of the use of force in custody isn’t good enough. This means that Thames Valley Police can’t always assure itself, or the public, that when force is used in custody it is necessary, justified and proportionate. This hasn’t improved enough since our last inspection and is part of our cause of concern for leadership and accountability.

The force has recently introduced a new process requiring custody inspectors to review use of force incidents. This replaces the previous process where this was the responsibility of a custody officer. However, at the time of our inspection, this wasn’t yet fully underway and not all inspectors had started their reviews.

We reviewed 20 use of force incidents. We found that when detainees were under restraint for long periods using handcuffs, spit hoods or leg restraints, custody officers didn’t always supervise incidents to make sure the ongoing force was necessary and proportionate. We also found that use of force incidents aren’t always recorded in enough detail on custody records, and not all police officers complete the required forms when they use force in custody. We had concerns in four cases and referred these to the force to review.

The force understands its responsibilities under the public sector equality duty. But it has provided limited training to help personnel understand diverse needs, for example relating to gender identity.

The force doesn’t collect data to assess if there are disproportionate outcomes for detainees and therefore it lacks strategic oversight. For example, it doesn’t measure outcomes by ethnicity or gender for:

• waiting times;
• average detention times;
• detainee care;
• use of force; or
• decisions whether to charge, bail or release detainees under investigation.

The force is open to external scrutiny. ICVs visit suites regularly and have a good working relationship with the force. They complete checklists following their visits. Any issues raised are dealt with at the time of the visit or at meetings between the force and the ICV scheme. The ICV scheme can access custody performance information and is involved in some custody monitoring arrangements. The ICV scheme manager also reported a good working relationship with the force.

Working with partners

The force has a priority to divert children and vulnerable adults away from custody and the criminal justice system.

It works with its local authorities to review cases where children are remanded in police custody after charge. It tries to influence the provision of more appropriate alternative accommodation provided by the local authority. However, despite these efforts, the lack of available alternative accommodation means few children are moved out of custody as they should be.

The force has a strong partnership focus on reducing reoffending by identifying vulnerability and making interventions to improve health, social care and criminal justice outcomes. There is a proactive approach to sharing information with partner agencies to provide support. For example, there is a referral service for women who offend which, between October 2023 and September 2024, made a high number of referrals to support agencies.

The force works with mental health services at a senior manager level to improve the outcomes for people who need this support. But it continues to face significant challenges when dealing with people with mental health conditions. As we found in our last inspection, detainees wait too long in custody for assessments under section 2 of the Mental Health Act 1983, or for beds at mental health facilities to become available. When police officers take people to hospital for mental health assessments, they can face long waits before being able to access the required health services.

There is a practice in the force where some people who are detained under section 136 of the Mental Health Act 1983 while in custody are released from custody and detained in other parts of police stations while they wait for an assessment. This may be well intentioned (for example to avoid long waits at hospital accident and emergency departments) but doesn’t follow the Mental Health Act legislation or APP guidance that states a police station should only be used as a place of safety in exceptional circumstances. It also potentially increases risk to both the detainee and officers who may not be equipped to deal with people in a mental health crisis.

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

The frontline officers we spoke to had a good understanding of how a person may be vulnerable and they take this into account when deciding whether to arrest or take other action. They said factors such as mental health conditions and learning or physical difficulties contributed to making a person vulnerable, as well as being under the influence of alcohol or drugs. Children are always treated as vulnerable, although the extent of this may vary according to the circumstances.

The force provides training to help frontline officers recognise and understand vulnerability. This training has included topics such as mental health, neurodiversity and dealing with children. The force has adopted the Right Care, Right Person model and has provided training on this to custody personnel.

Officers told us the information they receive from radio operators (also known as call handlers) in the force’s control room isn’t as good as it could be. They said they don’t always receive all the available information they need or at the time they need it. They believe this is mainly because the police radio channels are so busy.

Positively, children are arrested and taken to custody only as a last resort. Officers appropriately explore alternatives to custody. This includes practical solutions such as taking children back home to their parents or other family members and dealing with the incident there. If appropriate, officers may arrange for the child to attend the police station for an interview on a voluntary basis at a later date. Or they may consider other out of court disposals. However, sometimes it will be necessary to arrest a child due to the seriousness of the offence or if there are significant safeguarding concerns.

Frontline officers attending incident involving people with mental health conditions receive limited advice and help from mental health professionals. The force operates a street triage car staffed by a mental health professional and a police officer. Officers told us that this can be helpful, but the hours of operation are inconsistent and the support is sometimes unavailable, or only available in parts of the force area.

The force told us that they have tried to increase the frequency of this support, but mental health partners have been unable to provide the resources needed.

Officers told us that this limited help meant they lacked the information or knowledge to consider a full range of options. As a result, they often resorted to using their powers of detention under section 136 of the Mental Health Act 1983 for the safety of the person or others. When this happens, officers often face long waits with detainees waiting for ambulances to arrive, or to access a health-based place of safety. If mental health beds aren’t available, officers take detainees to hospital accident and emergency departments, where again there can be long waits. This is a poor outcome for those in mental health crisis and an inefficient use of police officer time.

Positively, officers don’t use police custody as a place of safety for people detained under section 136. However, sometimes people are arrested and detained in custody and later show signs that they may need help with their mental health. In these circumstances officers will continue to investigate any offences unless the detainee’s mental health deteriorates, or a Mental Health Act assessment determines that the detainee needs to be transferred to a mental health facility.

Sometimes detainees who need a further mental health assessment are released from police custody but are then detained under section 136 in other parts of the police station, such as the front office when it is closed to the public, or in a room with soft furnishings. Some officers told us they are uncomfortable with this practice and feel vulnerable because of the potential risks and lack of clear procedures.

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 treat detainees with respect and dignity. During our observations in suites, we saw how custody officers and detention officers showed empathy towards detainees during the booking-in processes and while carrying out cell checks.

However, at all suites there are no barriers between the desks in booking-in areas. This means that it can be hard to maintain privacy if there is more than one detainee present. Other than at Maidenhead, there are no discrete booking-in areas that could be used to have sensitive conversations or book in vulnerable detainees.

During the booking-in process we saw that custody personnel offered all detainees the chance to speak with a member of the same sex in private about their health and well-being. They also offer female detainees the opportunity to have a female officer available to support their needs while in custody, which is positive.

There is CCTV at all custody suites and there are signs pointing this out. During our observations, we saw that custody personnel routinely tell detainees about the CCTV operating in cells, and that the area on the monitors covering toilet areas are obscured from view.

Not all showers offer sufficient privacy to maintain detainee dignity due to the height of the doors or their position around a corner. At the time of our inspection one of the showers at Milton Keynes had a ceiling mirror angled so that detention officers can fully see a detainee showering while monitoring them for safety reasons. This is wholly inappropriate.

Meeting diverse and individual needs

Custody personnel understand how to meet the needs of detainees from protected or minority groups and do their best to meet these needs. We spoke with male and female adult detainees who told us they had been treated well while in custody.

The force responds well to the needs of female detainees. We saw that female detainees are allocated a female personnel member to oversee their welfare during their time in custody. They are offered feminine hygiene products and there is a good supply in all suites.

During booking-in, custody personnel routinely ask detainees of all ages and genders if they have caring responsibilities for others.

There is some provision to meet the needs of people with disabilities. All suites have:

• wheelchairs available;
• a limited supply of extra thick mattresses, and these are in a reasonable condition;
• sight lines in a small number of cells to help detainees with visual impairments navigate the confined space;
• hearing loops, to help detainees with hearing devices hear conversations more easily; and
• adapted communal toilet facilities.

Most suites have information about rights and entitlements available in Braille, and custody personnel could easily locate these.

However, Loddon Valley is the only suite that has higher benches for detainees with physical disabilities. The benches at the other suites are all low and so may not be suitable for detainees with mobility problems. There are no other adaptations in cells, although the force told us that the design of the new suites in its 2030 custody plan places importance on vulnerability and disability.

Custody personnel showed a reasonable knowledge of neurodiversity and said that they had received some awareness training. The force has a booklet to help autistic detainees understand what happens in police custody. In our case audits we saw that custody personnel paid attention to the diverse needs of adults and children.

The force has installed TV monitors in the holding areas where detainees wait to be booked into custody. These monitors provide visual and audio information about detainee rights and what to expect.

Some of the cells at Abingdon, Aylesbury, Loddon Valley and Maidenhead have glass‑fronted doors to help detainees who may feel anxious. We saw these being used.

Detainees can observe their faith while in custody. All suites have a suitable range of religious items, but these materials weren’t always stored appropriately.

There is adequate provision for detainees who speak little or no English. DA Languages provides interpretation services. Detainees can speak with interpreters at the booking-in desks using a three-way phone system.

Risk assessments

Custody officers make appropriate assessments to identify risk when booking detainees into custody.

Detainees waiting to be booked in are held outside in van docks that have been adapted with floor mats and fixed benches for this purpose. At Milton Keynes, custody personnel make use of the indoor holding rooms that are available.

However, during busy periods some detainees wait a long time to be booked into custody and may have to wait in police vehicles if there is no space in the van docks. This can increase the risk to detainees and officers. Custody officers usually make records of any delays and the reasons why, although this doesn’t always happen. In some cases, custody officers gave insufficient staffing as the reason for the delay.

Custody officers told us that they assess and prioritise booking-in detainees. We found some evidence of this with custody officers going to van docks to see who was waiting to be booked in. But this didn’t appear to be standard or consistent practice at all suites. Custody officers said their workload sometimes made it difficult to manage the queues during busy periods.

Before a detainee enters custody, arresting officers complete a form designed by the force. They include the grounds and necessity for the arrest and details of any risks, and then email the form to a custody mailbox. Custody officers then use this information to inform their initial risk assessment.

Custody officers carry out risk assessments and generally make appropriate decisions about how to manage risk. We saw some good examples of custody officers completing thorough and detailed risk assessments. But these weren’t consistently well recorded. For example, answers were sometimes limited to ‘yes’ or ‘no’ and didn’t have any free text to show that follow-up questions had been asked or considered. However, in our observations we saw that risk assessments were generally carried out to a better standard than was evident in custody records.

Custody officers generally set observation levels that match detainee risks. Positively, they make use of level 3 or level 4 constant observations for detainees at risk of self-harm, rather than placing them in anti-rip clothing. We saw that custody officers provide thorough briefings to officers tasked to carry out level 3 or level 4 constant observations. Officers complete an observation log, although it wasn’t always uploaded to the custody record.

However, in our case audits we saw that custody officers were appropriately setting observation levels at level 1 but supplementing this with a requirement for detention officers to monitor the detainee on the back-office CCTV. This extra precaution doesn’t follow APP guidance and means it isn’t clear what is expected or what the rationale is for managing risk.

Custody officers only remove a detainee’s clothing following an individual risk assessment. Force guidance is clear that, subject to a risk assessment, detainees can keep their shoes in cells. However, we found that custody personnel routinely remove footwear and leave it outside cell doors. This is contrary to APP guidance.

The force operates a process called SAFER that provides guidance to help manage the risk for intoxicated detainees by setting observation levels in line with levels of intoxication. However, we found that custody officers and HCPs weren’t always consistent in their approach to managing detainees under this process. For example, in our audits we saw cases where custody officers didn’t follow the observation level recommended by HCPs and there was no rationale for this on the custody record.

When detainees are placed on level 2 observations and require rousing, this is carried out appropriately. We found that detention officers carrying out these checks updated the custody record with free text entries that provided clear information about the care provided to detainees and considerations about risk.

In general, detention officers carry out cell checks on time and the same officer provides continuity of care and observations. In our case audits we saw some generic entries on custody records, but we observed checks being done in person that showed detention officers building rapport with detainees and treating people as individuals.

The force told us that custody managers dip sample records of detention officer checks, particularly for level 2 observations with rousing checks. Custody managers also accompany detention officers in person to observe how checks are carried out.

Handovers between shifts are of a good standard and held in an area where they can be recorded on CCTV. This is an improvement since our last inspection. Custody personnel and HCPs attend the handovers, and custody officers and detention officers then visit the detainees in their care.

If detainees need help, custody personnel answer cell call bells promptly and communicate well with detainees.

All detention officers carry anti-ligature knives. But some custody officers don’t carry these which means they may not have this equipment readily available if they need it in an emergency.

Keys are stored in secure cabinets, and we saw that custody personnel maintain good control of keys.

Individual legal rights – detention

Arresting officers provide information about the circumstances for the arrest and the necessity, as required by PACE code G 2012. However, they don’t always explain this to custody officers with the detainee present, to make sure that the detainee understands the reasons why they are in custody. When this information is provided remotely, custody officers don’t always authorise detention and record the grounds for detention with the detainee present, as required by paragraph 3.4 of PACE code C.

The force told us that it expects custody officers to go out to the van dock as part of their risk assessments, but they should be authorising detention at the booking-in desk. Senior leaders told us they were going to urgently address this issue.

However, the decisions to authorise detention were appropriate. The booking-in process is thorough and custody officers clearly explain the procedures. They also consider detainees’ welfare and vulnerabilities.

Custody officers scrutinise the grounds and necessity of the arrest before deciding whether to authorise detention for children and will look for alternatives where possible. Once detention is authorised for a child, they notify the custody inspector who then completes a review to check that detention is necessary. They also check that all relevant actions are in progress, including arrangements for AAs.

The force has introduced these reviews in addition to the statutory reviews of detention required by section 40 of PACE 1984. This is positive. We found they were completed in all cases and generally in a meaningful way. In some cases, we saw inspectors speaking directly to child detainees.

The force uses voluntary attendance as an alternative to arrest. There are enough interview rooms in police stations across the force so that people attending voluntary interviews can do so without having to enter custody.

The force makes appropriate use of bail or release under investigation, when further enquiries are needed and it isn’t possible to complete investigations in the first period of detention. We saw that custody officers appropriately authorise bail and make sure that any conditions or restrictions are necessary and proportionate. On release, they explain bail procedures to detainees in detail.

Custody officers record decisions to remand detainees post-charge on the custody records and we saw these were appropriate. But in our child case audits we found that custody officers didn’t record decisions to remand children in enough detail.

Individual legal rights – detainees’ rights and entitlements

During booking-in, custody officers clearly explain to detainees their rights and entitlements. These include:

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

All detainees receive a leaflet which outlines these ongoing rights and entitlements while in custody.

At the start of our inspection the force didn’t have any copies of the easy-read version of the rights and entitlements to give to detainees. We gave the force feedback and they quickly obtained supplies for all suites. We then saw custody officers handing these to detainees where needed.

There were enough copies of PACE code C books at all suites, but these weren’t the latest edition.

When detainees are held incommunicado (delaying their right to have someone informed of their arrest), this is appropriately authorised by an inspector or someone above the rank of inspector. The authority for this is removed when no longer needed and the detainee can have someone informed that they are in custody.

Posters advertising the right to free legal advice are displayed in suites, as required by paragraph 6.3 of PACE code C. But some of these, for example at Maidenhead and Milton Keynes, were worn and needed replacing.

There are enough interview and consultation rooms for detainees to privately consult with their legal representative. Detainees can also speak with their legal representative in private on the telephone. There are portable phones in the suites so that detainees can take calls in their cells. During our inspection we spoke to a duty solicitor who was positive about how the force makes sure that detainees can access legal advice promptly.

Custody officers we spoke to were aware of the requirements of annex M of PACE code C which states that detainees should receive documents and records of important information about custody processes in a language they can understand. We saw examples of custody officers providing these documents to foreign national detainees. Custody officers are aware of how to contact the relevant embassies, consulates or high commissions and we saw this happening in practice.

Reviews of detention

Reviews of detention for detainees aren’t always carried out in the best interests of detainees and don’t always comply with PACE and its codes of practice.

In our custody record audits we saw some records that indicated PACE reviews were carried out well and with reference to the detainee’s specific circumstances. But in other cases, the records were poor, and it wasn’t always clear that reviewing officers had spoken with detainees. Some records used a standard template with little text that was personalised to the individual detainee. This practice can make records appear contradictory and confusing to read. Reviews weren’t always completed on time. When reviews were early, inspectors didn’t always make a record of the reason why.

More positively, we regularly observed PACE reviews being carried out well by inspectors both in person and using the video live link system. Reviewing officers routinely established the progress of investigations by speaking with investigating officers to help them decide whether continued detention was necessary.

We saw that inspectors were courteous to detainees and provided updates on investigations. They reminded detainees of their ongoing rights and entitlements. They also considered welfare needs and asked detainees if they needed any more food and drink, or if they would like to take exercise, have a shower or have something to read. In our case audits we saw that inspectors considered the individual circumstances of child detainees, including welfare and access to AAs.

Inspectors generally carried out sleeping reviews during recognised rest periods only. But when a review of detention did take place while a detainee was asleep, detainees weren’t always told about the review at the earliest opportunity as required by PACE Code C paragraph 15.7. This is despite the custody system having a prompt to indicate that a sleeping review has taken place.

Complaints

Notices outlining how detainees can make a complaint are displayed at all custody suites.

Custody personnel we spoke to were aware of the force’s procedures if detainees want to make a complaint while in custody. However, during our inspection we found a case where a detainee asked to make a complaint and personnel told them to wait and go to the police station front office after release.

The force maintains a record of all complaints that shows the detail and progress of any investigations. But this information doesn’t indicate whether complaints are taken while detainees are in custody. The force told us the numbers of complaints are low and the custody leadership team reviews all cases. However, we didn’t find evidence about how the force analyses complaints and uses what it learns to improve custody services.

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

Thames Valley Police has six full-time designated custody suites in Abingdon, Aylesbury, Banbury, Loddon Valley, Maidenhead and Milton Keynes. There is a contingency suite at High Wycombe, and this was clean and ready for use if required.

All suites have potential ligature points, mainly due to the design of the toilets. There are also potential ligature points on cell intercom plates at Milton Keynes and some of the air vents at Loddon Valley. We found some of these potential ligature points in our last inspection. Custody personnel weren’t aware of all of these potential ligature points.

During our inspection, we gave the force a comprehensive report detailing these points, as well as the general conditions of the suites. The force started to consider how to address the concerns we identified.

The general conditions of the suites vary due to the age and design of the buildings. The suites are mostly well-maintained but there were differences in the overall cleanliness. For example, the suites at Loddon Valley and Milton Keynes were noticeably less clean than other suites, and Aylesbury was the cleanest.

Custody personnel at Milton Keynes use the designated holding rooms inside the suite for detainees waiting to be booked in. The holding rooms at the other five suites are considered unsuitable due to their proximity to the booking-in desks. Instead, detainees wait outside custody in the adapted van docks. However, these areas aren’t fully secure and some lead onto car parks or public areas.

There are no privacy barriers between the booking-in desks at any of the suites. This means that custody personnel are unable to maintain privacy when more than one detainee is in the booking-in area. Maidenhead is the only suite with a discrete booking-in area available for private conversations or booking-in vulnerable detainees.

Facilities in the suites sometimes make it difficult to meet detainee needs. The suite at Loddon Valley has some cells with higher benches but there are no cells with adaptations at any of the other suites to assist detainees with physical disabilities. All suites have a communal adapted toilet.

There are sinks and toilets in the cells at all suites, except a small number of designated dry cells (those without toilets and running water, used to preserve evidence while detainees wait for forensic samples to be taken). However, other than at Milton Keynes, there are no signs in cells stating that the water isn’t drinkable.

All suites except Milton Keynes have a quiet space where officers can carry out level 3 constant observations on CCTV. However sometimes other custody personnel use these spaces which risks distracting officers.

There is no exercise yard at Loddon Valley due to a decision to turn the previous space into a large storeroom. The lack of this facility can result in poor outcomes for detainees who are in custody for a long period of time, or who just want to go out of their cell for exercise. The other five suites have exercise yards, but only the yard at Milton Keynes provides cover for bad weather.

Custody personnel carry out daily and weekly safety maintenance checks of the suites, including cells and communal areas. These are completed and recorded as per APP. Personnel told us that repairs were mostly completed quickly.

There is CCTV coverage in most of the communal areas and in all the cells. Notices that CCTV is in operation are displayed where detainees can see them, and there are also notices in some of the cells. However, the force could put more signs up in the booking-in areas so detainees can access this information more easily.

During our inspection, we found some CCTV images were of a poor quality in suites that had yet to be upgraded. This was particularly noticeable at Loddon Valley, although the CCTV is scheduled to be upgraded in late 2024.

Custody personnel we spoke to were aware of emergency evacuation procedures, but few had taken part in a physical evacuation in the past year to make sure they can carry out the procedures in practice. Data provided by the force showed that in the last 12 months, personnel hadn’t completed the required evacuation drills at each suite. There are enough handcuffs to safely move detainees in the event of an evacuation.

Use of force

We reviewed 20 cases where force was used in custody. We examined custody records and viewed CCTV footage in all these cases.

In most cases the force was proportionate to the risk or threat posed. We saw officers were patient and most were respectful towards detainees. In 11 cases, we saw that officers controlled violent detainees appropriately and safely, using unarmed tactics and equipment such as handcuffs, spit hoods or leg restraints as necessary. Officers recognised the risks relating to acute behavioural disturbance and positional asphyxia.

However, in six cases officers didn’t apply handcuffs properly or they failed to maintain control of detainees. This included:

• a detainee who managed to change the position of their handcuffs;
• a detainee who escaped from the van dock while waiting to be booked into custody; and
• two detainees who attempted to self-harm in van docks.

In 17 of the 20 cases we reviewed, custody officers recorded use of force incidents in custody. This is better than we usually see. However, ten of the records didn’t have enough detail to explain what had happened, why it was necessary to use force and whether restraint equipment was used. We also found that custody officers didn’t always record when these restraints were removed or re-applied, particularly following incidents in the van dock while detainees were waiting to be booked in, or when they were on level 4 constant observations.

The force told us it had identified opportunities to improve the recording of use of force incidents. At the time of our inspection it had just created a new template for custody officers to use.

The force requires custody officers to record when detainees wait more than 30 minutes to be booked in and the reasons for any delay. This is so that there is monitoring and oversight of the time detainees spend in holding areas, including a review of the use of any force, such as restraints. But this didn’t always happen.

Some detainees spend too long in restraints while waiting to be booked into custody and we found delays of between 32 minutes and 1 hour 25 minutes. Some of these delays led to repeated use of force because of the extra time spent in van docks or in holding cells. This increased the risk of harm to detainees and officers. Custody officers didn’t review the ongoing necessity for detainees remaining in restraints.

In three cases, detainees remained handcuffed while on level 4 constant observations for periods ranging between three hours and nearly ten hours. We found no records that custody officers had carried out reviews to justify the continued use of handcuffs. In one case an inspector carried out a review of detention and the record didn’t include any comment about the detainee being handcuffed.

More positively, after placing violent detainees into cells, officers carried out cell exit techniques safely and in accordance with their training. Custody officers were present during these incidents and showed good leadership by giving clear direction to maintain the safety of officers and violent detainees. HCPs were also often present and carried out assessments in cells while detainees were being restrained.

Most strip searches carried out under section 54 PACE 1984 to look for concealed items were appropriately authorised, recorded and conducted adequately. However, some authorities lacked sufficient information to justify the necessity for the strip search. This was an area for improvement in our last inspection.

Custody officers use a standard template when authorising strip searches and this includes decisions about whether to use rooms with CCTV cameras. If they decide to keep cameras on for safety or evidential purposes, to protect the detainee’s dignity and privacy, custody officers must take steps to manage who can view the CCTV monitors. However, it wasn’t clear from the custody records whether the cameras were turned off or not.

Custody officers make a record of when they authorise the removal of a detainee’s own clothing for safety reasons and provide replacement clothing. However, the force doesn’t yet record these clothing swaps as strip searches, as per APP guidance.

Custody personnel showed a caring attitude towards detainees when carrying out strip searches to look for concealed items, or when removing a detainee’s clothing for safety reasons. They paid good attention to protecting detainee dignity. For example, by using clothing or blankets to cover any exposed body parts.

The force gives good scrutiny to incidents where children are strip searched but doesn’t scrutinise searches of adults.

The force dip samples use-of-force incidents in custody, and this includes viewing the CCTV footage. However, this quality assurance process hasn’t identified some of the concerns we have raised. At the time of our inspection the force had recently introduced a new process where custody inspectors will be responsible for reviewing eight cases per month. Not all inspectors had started these reviews yet.

We referred four cases to the force for learning that included concerns we had about:

• the recording and conduct of strip searches;
• incidents involving what we considered to be the use of excessive force; and
• a concern over unprofessional comments made to detainees.

The force provided an immediate positive response to these referrals, identifying opportunities to improve practice.

Officers who use force on detainees in custody don’t always submit individual use of force forms as required by National Police Chiefs’ Council guidance. We asked for use of force forms for the incidents we reviewed. We were expecting 119 and received 80 forms.

Detainee care

The force provides a reasonable level of care to detainees. Custody personnel show a caring attitude to detainees, and we saw good examples of this during our inspection.

There is an adequate range of food and drink. Custody personnel offer this to detainees mainly at recognised mealtimes, but it is also provided upon request. The force caters for most dietary and cultural requirements.

During the booking-in process custody officers use a template that includes a prompt to tell detainees about the provisions available to them such as showers, exercise and reading material. We found that detainees were offered showers before attending court, but it wasn’t always clearly recorded that showers were routinely offered. We also found little evidence of detainees using exercise yards.

There is an adequate supply of distraction materials at all custody suites, and we saw detainees using these during our visits. However, in our custody record audits we found records didn’t show these were routinely offered or provided.

Most suites have a limited range of books and other reading materials, although there is a better supply at Loddon Valley. Foreign language titles and reading material for children were limited. During our suite observations we saw custody personnel offer reading materials and we saw some detainees with books and magazines in their cells.

Toilet tissue is readily available in the cells, subject to a risk assessment.

There is good supply of replacement clothing and footwear in a range of sizes.

There are pillows and mattresses in all cells. However, some of the thin mattresses appeared worn and were damaged due to the way they are stored. This was particularly noticeable at Loddon Valley.

There is a good supply of towels and blankets in all suites.

Safeguarding children and vulnerable people

The force works with its partner organisations to improve safeguarding outcomes for children and vulnerable adults. Custody personnel take account of safeguarding concerns, but this isn’t always reflected in custody records.

The force’s policy outlines the responsibilities of custody officers to identify the needs of vulnerable detainees and make sure that appropriate action is taken to safeguard their welfare. The force expects custody personnel to follow APP and its own guidance.

The force provides relevant training on topics such as understanding how previous trauma can affect detainees in custody and has also worked with Samaritans. However, some custody personnel we spoke to couldn’t recall any recent training.

The force told us it has worked with partner organisations to improve the safeguarding outcomes for vulnerable adults. This has focused on diverting women from the criminal justice system as well as the needs of veterans and people who are homeless. There is also some work on neurodiversity, such as providing distraction packs and putting chalkboards in cells.

During our observations in the suites, we saw examples of custody officers considering the needs of vulnerable adults and juveniles during the booking-in and release process. This included making referrals to charities and making sure that safeguarding risks were followed up. However, some of the pre-release risk assessments we examined during our case audits didn’t show how safeguarding concerns had been dealt with.

Custody officers routinely make referrals to the L&D team and the HCP for all children detained in custody. In our case audits we found that children were seen promptly. Arresting officers must make additional referrals to the force’s multi-agency safeguarding hub (MASH) and the force has processes to make sure this is done.

Appropriate adults

Custody personnel make prompt requests for appropriate adults (AAs) to attend custody, but there are sometimes delays in attendance. Due to the statutory arrangements with children’s social care, the service is better for children than it is for vulnerable adults. The force measures the time that AAs attend custody after the request is made.

The force expects AAs to attend custody for rights and entitlements and for interviews. Custody personnel will first consider family, friends or others known to the detainee to act as the AA for children or vulnerable adults.

Where AAs aren’t available, or if they are unsuitable, the force uses the youth offending teams between 9am and 5pm or the emergency duty teams out of hours to provide this support for children. Adult social care provides the service for adults.

If these teams can’t provide an AA, custody personnel can seek authority from an inspector to fund this service from Appropriate Adults UK. Custody personnel told us that the cost isn’t a barrier to accessing this service, but by the time the request is made there are already delays.

The force told us that its 9 local authorities have committed to providing AAs 24 hours a day, 7 days a week. But there are sometimes delays in accessing AAs, particularly at night and for vulnerable adults. The AA provision varies across the force area. Positively, Milton Keynes benefits from a group of volunteers who can attend the custody suite promptly and we saw an example of an AA attending custody within 15 minutes of the request.

In our child audits, we found that custody officers made prompt requests for AAs. Family members generally attended early in the detention period, but there were sometimes long delays before the youth offending team or social services were able to attend. Delays in obtaining AAs meant that some children and vulnerable adults spend longer than necessary in custody, particularly overnight. This is due to the delay in progressing the custody and investigative processes.

In our observations in suites, we saw examples of arresting officers making early requests for AAs for children, and custody officers followed this up during booking-in. We saw that custody officers actively involved AAs in the custody process and provided information about the role of the AA to family members carrying out this role.

Positively, it is common practice in the force for children to spend time in separate rooms in custody with their AA, rather than in a cell. We saw plenty of evidence of this in our audits and in our observations in suites.

Children

The force is clear that children should be arrested only when necessary. It works well with its youth justice partners to divert children away from custody. It proactively looks for opportunities to use out of court disposals, particularly community resolutions. Where possible, multi-agency youth justice panels review cases to avoid criminalising children.

When a child is brought into custody, custody officers scrutinise the grounds for arrest and will refuse detention where necessary. The force monitors this. During our inspection we found that when children were arrested it was generally for relatively serious offences. But records didn’t always show the same considerations that we saw during our observations in the suites. For example, in a few cases it wasn’t clear that alternatives to custody had been considered when, in our view, this may have been an option.

Custody personnel act in the best interests of children to safeguard their welfare. We saw custody officers were empathic and reassuring when booking-in children and considered their needs. In our case audits we found that risk assessments considered health or diverse needs and custody personnel provided good levels of care. We found that all girls under 18 were allocated a female carer and custody officers made a record of this. During our observations we saw custody officers also allocated a detention officer to oversee the care of male children, but we didn’t see this recorded in the case audits.

Custody officers make sure that parents or guardians are informed when a child is detained in custody and make early contact with AAs. Children are proactively given access to legal representatives to safeguard their interests.

There are no discrete booking-in areas other than at Maidenhead. But we saw good examples of custody officers keeping children separate from adults who were volatile or who had committed sexual offences. All suites, except Maidenhead and Loddon Valley, have separate cells for children and young people.

In our case audits we found investigating officers dealt with children more quickly than adults. We also saw cases dealt with promptly and custody officers and PACE inspectors chasing progress to minimise the time children spend in detention. Where there were delays these were usually due to the lack of AA availability.

However, in our case audits we found there was little rationale recorded when children were detained overnight in custody (pre and post charge), even if the circumstances seemed appropriate. We gave the force feedback on these cases.

When children are remanded overnight after charge they aren’t moved to alternative accommodation. Data provided by the force shows that in the 12 months to July 2024, the force made 49 requests to the local authority for secure accommodation. And it made six requests for non-secure accommodation. The local authority couldn’t meet any of these requests, which was a poor outcome for the children detained overnight in custody.

The force is working with its nine local authority partners to try to address this issue. There is a quarterly meeting that reviews all cases where children are remanded, and requests were made for alternative accommodation. The force told us it has an internal escalation process. But there is no secure accommodation nearby and it isn’t in the best interests of the child to travel long distances.

In our audits we found that personnel didn’t always clearly record requests for alternative accommodation after charge in custody records. In two cases the juvenile detention certificates were missing.

The force has a series of processes to scrutinise cases where children are in police detention. This includes daily management meetings, review of data including decisions to authorise detention, scrutiny of strip searches and meetings with partners where all remand cases are reviewed.

Healthcare

Mountain Healthcare Limited (MHL) provides physical healthcare services for detainees 24 hours a day, 7 days a week. The force monitors the healthcare contract through regular performance meetings.

There is good joint working between the force and MHL with robust governance arrangements to monitor the safety and quality of the service. There are appropriate information-sharing agreements between health partners and the force, and MHL can access the appropriate information from community health records for detainees while in custody.

HCPs are based at all custody suites. There are enough HCPs to provide sufficient cover and meet demand at all suites.

HCPs receive appropriate training, which includes safeguarding training so they can recognise and manage detainees’ vulnerabilities. They also receive annual performance appraisals. All HCPs have access to clinical support and regular manager supervision, and they told us they felt well supported in their roles.

Clinical rooms are tidy and well-equipped and comply with infection prevention and control guidelines. HCPs monitor room temperatures to ensure the integrity of medicines stored in the room. A contract is in place for daily cleaning of the rooms. Emergency equipment is available to respond to an emergency situation and HCPs check this kit regularly. HCPs have access to police automated external defibrillators.

HCPs can access interpreters for detainees whose first language isn’t English.

HCPs report any incidents online for MHL managers to investigate. Learning from incidents is shared with HCPs during team meetings and supervision forums.

MHL has a confidential complaints process, which is advertised to detainees in custody suites on posters or in leaflets.

Physical health

Competent HCPs provide prompt clinical assessment and treatment to detainees. HCPs we spoke with were knowledgeable and compassionate about their role in helping detainees. Custody personnel were also positive about the interactions they had with HCPs and the proactive approach that HCPs take in the custody suites.

HCPs obtain consent from detainees to carry out assessments of physical and mental health (including their mental capacity), substance misuse, social care and safeguarding. HCPs contribute to decisions regarding risk, such as fitness to detain, and interview. They record detailed clinical assessments on MHL’s electronic system and record a summary with key risk information on the force’s custody system for custody personnel.

HCPs see detainees in private unless a risk assessment indicates otherwise, in which case a member of the custody team would remain close by. However, not all clinical rooms have privacy screens. Where they are available, they aren’t consistently used to protect detainee dignity during clinical examinations. This is poor.

Mental health

During their hours of operation, L&D teams provide a comprehensive service across the force. L&D practitioners are based in most custody suites and provide support to vulnerable detainees with a range of needs, this includes providing advice and referrals for substance misuse issues. Staffing levels have improved, and support workers and peer mentors are available to help detainees after they leave custody.

L&D teams have recently increased their hours of working in the suites and are available from 8am to 8pm. Custody personnel can continue to refer detainees to L&D teams outside these hours. But if detainees are released before they arrive in the suites, there is no resource or funding for the L&D team to follow up these referrals. This is a gap in the service. The youth services team follow up any referrals for detainees under the age of 18.

Custody personnel refer detainees to L&D by email. L&D practitioners triage referrals each morning and monitor any further referrals throughout the day. They prioritise those detainees with the greatest risk or need, and provide a good standard of assessment, including onward referrals for support on release.

L&D practitioners work well with custody teams to meet individual’s needs, including identification and support for those with neurodiverse needs. Practitioners are based in all custody suites, supporting the communication and joint working between HCPs and custody teams.

Clinical records are stored securely on each healthcare trust’s electronic record system. L&D practitioners have access to community mental health records in the local area. They also record relevant information on the custody record to make sure that custody personnel are aware of this and any risk factors.

Positively, the force monitors data on the number of detainees assessed under the Mental Health Act while in custody, how long they wait for an assessment and, if required, how long they wait for a bed. However, detainees with severe mental health needs still face significant delays when waiting for a Mental Health Act assessment and secure bed.

In some force areas there is a preference to move detainees out of custody for a mental health assessment. However, there are significant delays both at health-based places of safety and in finding a bed for those assessed as suitable. As a result, outcomes for detainees requiring an assessment or secure bed are poor.

There is good partnership working between the force, L&D and health-based places of safety to address the challenges and delays detainees face.

There is limited support for frontline officers when managing detainees with mental health needs. There is no control room support. The arrangements for street triage are inconsistent across the force area and don’t always operate.

Substance misuse

L&D practitioners provide support for detainees with substance misuse needs. They can make referrals to community services and support workers who encourage detainees to attend appointments following release from custody.

HCPs assess and provide treatment for detainees withdrawing from drugs and alcohol while in custody. HCPs use nationally recognised clinical tools to make decisions and monitor detainees’ treatment needs while in custody. When required, HCPs administer medicines to relieve symptoms of withdrawal.

Under the healthcare provider’s policy, HCPs aren’t permitted to issue detainees with their prescribed opiate substitution medication, which potentially places detainees at risk of overdose or other complications when they are released from custody. Instead, HCPs are only able to offer symptomatic relief. The force and MHL have recognised this issue. MHL has plans to change this practice and started a trial in September 2024 to offer detainees their prescribed methadone while in custody.

Medicines management

There are good governance arrangements to manage medicines safely. Medicines, including controlled drugs, are stored safely. HCPs and clinical team leaders carry out daily audits and stock checks. Custody personnel store detainees’ own labelled medicines securely in the detainees’ property locker. HCPs also assess the detainee before administering any of their own prescribed medicines.

Patient Group Directions are available electronically to support personnel with decision-making on health issues such as asthma, pain and acute withdrawal from alcohol and drugs.

Personnel report medicine errors on an electronic reporting system and managers investigate these promptly.

The force doesn’t provide nicotine replacement therapy for detainees. This is poor.

Section 5. Release and transfer from custody

Expected outcomes: Release and transfer from custody

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

Safe release and transfer arrangements

Custody officers generally make sure detainees are released safely. But PRRAs don’t always contain enough detail to show they have identified the potential risks when detainees leave custody.

Custody officers rely on the standard drop-down menus when completing PRRAs. And they don’t always use follow-up questions to explore the answers detainees provide. In some cases, custody records showed answers to the PRRA as ‘yes’ or ‘no’ answers with no free text added to record risks that were apparent while the detainee was in custody. However, in our observations, we found that the completion of PRRAs was more thorough and personalised in person than shown on custody record entries.

On release, custody personnel provide detainees with an information leaflet about available support services.

When detainees are arrested for certain sex offences, custody officers carry out an enhanced PRRA. These take place with a member of the L&D team and the investigating officer. We saw examples of custody officers showing sensitivity and awareness of risk when managing the release of detainees in these circumstances.

Custody officers generally ask detainees how they are getting home and if they have the means to do so. But, in our audits, we found two cases where no record had been made of how female adult detainees were getting home in the early hours of the morning.

Before detainees are transferred to court, detention officers complete d-PERS. Custody officers check these for accuracy before signing them off.

Custody officers also lead the handover of detainees and provide an update on detainee risks, including any medical concerns. We saw custody officers speaking personally with detainees to check on their welfare before releasing them. This is positive, although it wasn’t always done in private.

Courts

Detainees are dressed in appropriate clothes when they are released from custody to attend court.

The force’s transport contractor, Serco, isn’t always able to collect detainees promptly to take them to court. There are no fixed arrival times and sometimes collection is cancelled at short notice. The force has taken steps to improve this situation and there is a daily call between the custody manager and the Serco manager. The force told us this has helped to minimise the time detainees spend in custody after charge by getting them to court promptly.

Courts in the Thames Valley Police area will generally accept late admissions up to 2pm. In these circumstances, police officers will promptly take detainees to court. However, the courts are sometimes at capacity which means that some detainees have to wait longer in police custody before attending court.

There are virtual court facilities at all suites.

Section 6. Summary of cause of concern, recommendation and areas for improvement

Cause of concern and recommendation

Areas for improvement

First point of contact

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
• Sarah Edgar: HMICFRS inspection officer
• Julie Mead: HMICFRS inspection officer
• Andrew Reed: HMICFRS inspection officer
• Justine Wilson: HMICFRS inspection officer
• Dayni Johnson: CQC inspector
• Matthew Tedstone: CQC inspector

Fact page

Note: Data supplied by the force.

Force

Thames Valley Police

Chief constable

Jason Hogg

Police and crime commissioner

Matthew Barber

Geographical area

Oxfordshire, Berkshire, Buckinghamshire

Date of last police custody inspection

February 2018

Custody suites

• Abingdon (30 cells)
• Aylesbury (24 cells – operates at 50 percent capacity)
• Banbury (12 cells)
• High Wycombe (contingency suite)
• Loddon Valley (28 cells)
• Maidenhead (26 cells)
• Milton Keynes (24 cells)

Annual custody throughput

34,153 (2023–2024)

Custody staffing

• One chief superintendent
• One superintendent
• Two chief inspectors
• Four custody suite inspectors
• 11 PACE inspectors (6 in post)
• 82 custody officers
• 150 detention officers (131 in post)
• 14 officers and staff covering support, police and training roles

Health service provider

Mountain Healthcare Limited (MHL)

Back to publication

Report on an inspection visit to police custody suites in Thames Valley Police