Report on an unannounced inspection visit to police custody suites in Gloucestershire

Summary

This report describes our findings following an inspection of Gloucestershire Constabulary custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and HM Inspectorate of Prisons (HMIP) in February 2022. 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.

This inspection took place during the pandemic. We continue to adapt our ways of working to manage the risks as the pandemic continues. We gave the force more notice of the inspection than usual. And we carried out our interviews and focus groups remotely. We made our observations over the two-week period, but we limited the number of our inspectors in the suite at any one time.

We last inspected custody facilities in Gloucestershire in 2015. We found that of the 19 recommendations made during the 2015 inspection, the force has fully or partially achieved 11.

To help the force improve, we have made three recommendations to them (and the police and crime commissioner). These address our main causes of concern. We have also highlighted a further ten areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and partnerships

Gloucestershire Constabulary has a clear governance structure for the safe and respectful provision of custody services. But the strategic and operational arrangements for overseeing custody aren’t good enough in scrutinising the provision of custody services. Some important areas haven’t improved since our last inspection in 2015. Our causes of concern in this inspection are mainly due to lack of governance and oversight.

There is one large custody suite at Quedgeley. Generally, there are enough staff on duty to manage safe detention. The force delivers many aspects of custody services well, to keep detainees safe and meet their needs.

But the force doesn’t know how well it is providing its custody services. It carries out some performance monitoring, but important areas are missing – for example, how long detainees wait if they need a Mental Health Act assessment in custody. Some of the information the force needs to assess performance is either unavailable or inaccurate. Poor recording on custody records, and little quality assurance over them, also hinders effective performance management.

There is limited strategic oversight and governance of the use of force. The force doesn’t accurately collect or monitor information to show what type of force is used in custody, how often, and by which officers. There is little quality assurance of incidents to assess how well staff handle them. Our own review of incidents on CCTV showed that staff handle most incidents well, in ways that are necessary and proportionate to the risk posed. But without better oversight, the force can’t assure itself, the police and crime commissioner and the public that this is always the case.

The force doesn’t always follow the Police and Criminal Evidence Act 1984 (PACE), its codes of practice and other legislation, for example, in some aspects of reviews of detention. Neither does it consistently follow the College of Policing’s Authorised Professional Practice (APP) – Detention and Custody, especially when managing detainee risks.

The force has a good understanding of the public sector equality duty. And it is committed to meeting that duty. It has carried out work to identify and address any disproportionality in relation to young people, women and ethnic minorities.

There is a clear priority to divert children and vulnerable adults away from custody. The force works well with its partner agencies to achieve this. For example, the multi-agency Children First panel and Youth Support Team (YST) aims to support children and keep them out of custody and the criminal justice system where possible. The force also works with mental health partners to identify and meet the needs of those with mental ill health.

Pre-custody: first point of contact

Frontline officers we spoke to have a good understanding of vulnerability. They take account of vulnerability when deciding whether to arrest a person. They divert children from custody as much as possible, helped by multi-agency schemes.

There is limited support for frontline officers dealing with people with mental ill health. Advice from mental health services is available, but this doesn’t always allow officers to arrange health-based options. This can lead to them detaining the person under section 136 of the Mental Health Act 1983 to manage the risks the person poses to themself or others.

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

Custody staff interact respectfully with detainees. They recognise detainees’ individual and diverse needs, and they generally do their best to meet them. Privacy for detainees, especially when disclosing sensitive information, isn’t always maintained. Some custody practices don’t protect detainees’ dignity well enough, for example, routinely removing footwear but not always replacing it.

The identification of risk is generally good. Observations of detainees are generally set at a level commensurate with presenting risks. Staff make checks on time. When close observations are needed, staff carry them out well.

But the force doesn’t consistently follow APP guidance. For example, some detainees under the influence of alcohol and/or drugs aren’t monitored at the level required by APP. And custody staff routinely remove detainees’ clothing with cords, as well as their footwear, rather than individually risk assessing the need for this.

Custody officers usually book detainees into custody promptly and appropriately authorise their detention. Custody officers try to make sure cases are progressed as soon as they can be. But reviews of detention aren’t always carried out well. Reviews don’t always meet the requirements of PACE and its codes of practice.

When detainees are released under investigation, officers explain this to them. They give these detainees a notice about what it means if they interfere with victims or witnesses during the investigation.

Custody officers give detainees good explanations about their rights and entitlements. But they don’t always tell them they can read the PACE Code C booklet, offer it to them or give them a rights and entitlements leaflet, as required by PACE Code C paragraph 3.2. Detainees wishing to make a complaint while in custody can do so before they are released.

In the custody cell, safeguarding and health care

General conditions in the custody suite are good. Cells are well maintained but are only superficially clean. There are potential ligature points in the suite due to the design of the toilets. We gave the force a comprehensive illustrative report detailing the general conditions we found during the inspection. They acted on this and told us they had arranged a programme of deep cleaning for each wing.

The approach to looking after detainees is reasonably good. The detainees we spoke to were generally positive about the care they received. Staff offer food and drink regularly, but we rarely saw them offering or providing exercise, showers or reading material to detainees. They usually only give distraction activities to children.

Officers we spoke to understand their responsibilities to safeguard children and vulnerable adults. The YST supports children and makes safeguarding arrangements as needed, which gives extra assurance. But children and vulnerable adults aren’t consistently receiving prompt support from appropriate adults (AAs). Some wait a long time before their AA arrives.

Staff generally care for children in custody well. Some areas need improving, such as giving out easy-read versions of the rights and entitlements leaflet. And girls aren’t always assigned a female member of staff to oversee their welfare in custody, as required by law.

Custody officers try to minimise the time children spend in custody and they avoid keeping children overnight where possible. Those charged and refused bail should be moved to alternative accommodation arranged through the local authority. But this doesn’t always happen.

Health care for detainees is generally good. Experienced healthcare practitioners (HCPs) give patients appropriate care and treatment. The force manages the contract well and practitioners see most detainees within the agreed response times. Opiate substitution treatment and symptomatic relief can be given to detainees experiencing acute drug and alcohol withdrawals, and custody staff can administer nicotine replacement products.

The liaison and diversion (L&D) service gives effective support to detainees with mental ill health or other vulnerabilities, including follow-up support in the community. There are specific schemes to help women and veterans.

Mental Health Act assessments are arranged in custody when necessary, but detainees subsequently needing to transfer to a health-based place of safety aren’t always moved. Sometimes this leads to the force detaining the person under section 136 of the Mental Health Act 1983 so they can take them to the health-based place of safety. There is little information to show when, and in what circumstances, this happens.

Release and transfer from custody

The force has a clear focus on releasing detainees safely. Custody officers engage well with detainees to address or reduce any risks that have been identified. They help detainees get home safely.

But custody officers aren’t speaking to detainees who are transferring to court or recalled to prison when carrying out pre-release risks assessments. Detention officers don’t always complete digital person escort records (dPERs) for these detainees well enough, and custody officers don’t always check them, contrary to APP guidance.

Once detainees are remanded in custody, they are generally presented before the first available court. This means most aren’t held for any longer than necessary.

Causes of concern and recommendations

Introduction

This report is one in a series of inspections of police custody carried out jointly by HM Inspectorate of Constabulary & Fire and Rescue Services (HMICFRS) and HM Inspectorate of Prisons (HMIP). 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 Optional Protocol to the UN Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment (OPCAT).

The joint HMICFRS/HMIP national rolling programme of unannounced 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. HMIP and HMICFRS 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 drive improvement.

The expectations are grouped under five inspection areas:

• leadership, accountability and partnerships;
• pre-custody: first point of contact;
• in the custody suite: booking in, individual needs and legal rights;
• in the custody cell: safeguarding and health care; and
• release and transfer from custody.

The inspections also assess compliance with the Police and Criminal Evidence Act 1984 (PACE) 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 staff;
• 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 Gloucestershire Constabulary we analysed a sample of 109 records. The methodology for our inspection is set out in full at Appendix I.

Section 1. Leadership, accountability and partnerships

Expected outcomes (section 1)

There is a strategic focus on custody, including arrangements for diverting the most vulnerable from custody. There are arrangements to ensure custody-specific policies and procedures protect the wellbeing of detainees.

Leadership

Gloucestershire Constabulary has a clear governance structure for the safe and respectful provision of custody services. An assistant chief constable (ACC) has overall accountability, supported by a superintendent. A chief inspector is responsible for the day-to-day management of custody operations.

There are strategic and operational arrangements for overseeing the provision of custody services. Fortnightly criminal justice meetings include representatives from outside bodies and there is an operational policing board chaired by the ACC. But these groups have little oversight of custody matters. Not enough progress has been made against the recommendations from our last inspection in 2015. Of the 19 recommendations we made, the force has only achieved or partially achieved 11 of them. Some important areas haven’t improved and have now become causes of concern.

The force has recognised the shortfalls in its governance arrangements and it plans to improve strategic oversight through new quarterly performance meetings chaired by the ACC. But the lack of oversight is a cause of concern.

The force provides its custody services at one large custody suite in Quedgeley. Staffing consists of 2 inspectors, 15 custody officers, 4 lead detention officers and 28 detention officers. Our observations show there are generally enough staff on each shift to manage safe detention.

There are some difficulties in covering staff absences. Trained sergeants from local policing teams act as custody officers to maintain staffing levels when needed. Custody officers on overtime cover detention officer absences. Detention officers became Gloucestershire police staff in April 2021. (Previously they were provided by an external contractor.) This offers more flexibility in how they are used. The force plans to build a pool of detention officers so it can provide cover more appropriately in future.

Initial training is comprehensive. All new staff complete a workplace assessment and receive a period of mentoring from experienced custody staff before starting their duties. Custody officers have a two-day annual refresher course and an additional eight training days each year as part of their shift pattern, although staff told us these days are rarely used for training.

Detention officers don’t have ongoing structured training, which was an area for improvement from our last inspection. The handover period between shifts is sometimes used to give awareness sessions, such as presentations from AAs and mental health professionals. Staff told us they would appreciate more training sessions.

The force has adopted the College of Policing’s APP – Detention and Custody. It also has its own custody manual. But some custody practices don’t follow either guidance. The force doesn’t always follow APP in managing detainee risks, for example, and not all staff carry anti-ligature knives. Cell keys aren’t always managed in accordance with the force’s own custody manual, nor is the completion of daily safety checks.

The force’s guidance allows staff to manage detainee risks by removing clothing and leaving the detainee naked in their cell with only a blanket. This is disrespectful and inappropriate. We expect this guidance to be changed immediately.

There have been no deaths in custody since our inspection in 2015.

The force has a process for recording adverse incidents. (An adverse incident means any incident which, if allowed to continue to its ultimate conclusion, could have resulted in death or serious injury to any person.) Incidents are shared with senior managers and force health and safety representatives. But not all staff we spoke to were aware of how to recognise and record adverse incidents. We found cases where adverse incidents should have been recorded but had not been.

Accountability

There is little monitoring to assess how well custody services perform and the outcomes achieved for detainees. The force monitors some aspects of custody services at the criminal justice meeting and operational policing board. This includes the number of detainees entering custody, the time detainees wait to be booked in, children in custody and the number of detainees on bail. But the force doesn’t monitor other important areas of performance because it doesn’t collect the information to do this. For example, it doesn’t monitor how long detainees wait for Mental Health Act assessments or for support from an AA.

The force has difficulties in getting some performance information from its computer system. We requested information for our inspection, but the force was unable to provide some of it, such as the average time detainees spend in custody overall. Other information is inaccurate, including information about the use of restraint equipment in custody. The level and quality of performance information doesn’t allow the force to effectively assess how well custody services perform, or to identify where it needs to make improvements. It forms part of our cause of concern about the lack of oversight.

The force doesn’t make sure it consistently follows the PACE, its codes of practice and other legislation. This includes:

• not telling detainees they can read the PACE Code C booklet;
• not giving them a written copy of their rights and entitlements (PACE Code C paragraph 3.2);
• not informing detainees when a review has taken place while they were asleep (PACE Code C paragraph 15.7); and
• not assigning girls to the care of a woman, as required by the Children and Young Persons Act 1933.

This is a cause of concern.

The force can’t assure itself, the police and crime commissioner and the public that the use of force in its custody suite is necessary, justified and proportionate.

There is little strategic or operational oversight of the use of force, and most of the information to support this oversight is either missing or inaccurate. The force has a use of force monitoring system, but staff don’t always complete the use of force forms this system relies on, as required by the National Police Chiefs’ Council (NPCC) guidance. This means not all incidents are recorded.

The force can’t obtain this information other than from its custody computer system. The lack of proper recording on custody records about when and what force is used exacerbates this problem.

The governance and oversight of the use of force in custody hasn’t improved since our last inspection in 2015, despite our recommendation. It is a cause of concern. But our own review of incidents on CCTV showed most techniques used were appropriate and that the force used was necessary, justified and proportionate. We referred one case back to the force for learning.

The quality of recording on custody records is poor. Some information is confusing, missing or inaccurate. We did see some very detailed entries on custody records, but important information is sometimes missing. Examples of missing information include:

• referrals of detainees to L&D services; and
• whether the force gives detainees and their legal representatives the opportunity to make representations before superintendents authorise detention to be extended for more than 24 hours.

Detention logs aren’t always chronological and some entries are recorded late, making it difficult to follow what has happened and when. The use of some pre-populated texts within the system, together with a record of actions taken, can lead to contradictory information.

Quality assurance of custody records is limited. There is some dip sampling, with the recently formed custody scrutiny panel reviewing 30 records every 2 months. But these reviews haven’t identified the concerns we have found. The quality of custody records forms part of our cause of concern about the oversight of custody.

The force has a good understanding of the public sector equality duty. And it is committed to meeting that duty. Custody staff receive training on the Equality Act 2010 as part of their initial training, but there is limited ongoing training to raise awareness of specific vulnerabilities such as autism.

Detainees’ ethnicity is captured on most custody records. Detainees are asked to self‑define their ethnicity, but usually only if the information isn’t already held from a previous arrest. This may mean the information isn’t always accurate.

There is a clear commitment to monitoring custody outcomes to ensure they are fair. The custody scrutiny board has carried out work to identify and address any disproportionality in relation to young people, women and ethnic minorities.

The force is open to external scrutiny. Independent Custody Visitors (ICVs) conduct weekly visits. Custody staff are responsive to dealing with issues raised by ICVs and there are regular meetings between the scheme manager and the chief inspector. But some repeat concerns raised by ICVs, such as the cleanliness of cells and the storage of toilet paper, are problems that we have also found during this inspection. This suggests the force doesn’t always act on feedback. But it is positive that ICVs are part of the custody scrutiny panel, giving some independent oversight of custody performance.

Strategic partnerships to divert people from custody

There is a clear priority to divert children and vulnerable adults from custody, and staff understand this.

The force works well with other services and organisations to reduce re-offending by children and keep them out of the criminal justice system. The Children First panel, made up of representatives from different organisations, considers options and interventions to divert children away from custody and to help prevent further offending.

The Gloucestershire YST working in custody provides support for children while they are in custody. The team also offers support to officers dealing with incidents on the street, to try to help prevent child arrests where appropriate.

The success of Children First has led to the force providing a similar approach for adults – DEPEND. This scheme is for adults who have committed offences or have been in custody, and it offers diversion options. Staff we spoke to were aware of and spoke positively about both schemes.

The force works with its mental health partners at a strategic level to identify and meet the needs of those with mental ill health. The L&D service based in custody works well to support detainees with mental ill health, both in custody and on their release. But difficulties remain in getting appropriate help for individuals with mental ill health who come to police attention on the street.

Section 2. Pre-custody: first point of contact

Expected outcomes (section 2)

Police officers and staff actively consider alternatives to custody and in particular are alert to, identify and effectively respond to vulnerabilities that may increase the risk of harm. They divert away from custody vulnerable people whose detention may not be appropriate.

Assessment at first point of contact

Frontline officers we spoke to have a good understanding of the factors to consider when assessing whether a person is vulnerable. They said age, mental ill health and learning difficulties can all contribute to someone’s vulnerability. All children are regarded as vulnerable, but officers said some children, such as those in care, have additional vulnerabilities. Officers told us they take account of different vulnerabilities when deciding whether to arrest a person or look for alternative actions. But the risks the person poses to themselves or others, and the type of offence, are also important determining factors.

The force has a definition for vulnerability and most officers are aware of this. There is training on vulnerability for new police officers. But there is little follow-up training, and any given is mainly through e-learning. Officers told us they often rely on each other for guidance and support when dealing with vulnerable people. But all those we spoke to recognise the importance of their role in safeguarding children and vulnerable people.

Information from call handlers in the force control room (who take calls from members of the public) is generally good enough to help officers deal with incidents. Officers said they sometimes need to ask the call handlers to find out more information, but getting this depends on how busy the call handlers are. However, officers can access most information held about individuals on their own hand-held devices. They feel that this, along with information given by the call handlers, allows them to make informed decisions about what action to take.

Frontline officers are very focused on keeping children out of custody. They consider alternatives such as:

• taking children to another family member when a situation needs calming down;
• arranging for children to attend a police station for a voluntary interview; and
• exploring restorative justice options.

Officers also spoke positively about work with other agencies and schools to address offending behaviour and avoid taking children into custody.

There are good arrangements to help officers find alternatives to children entering custody. The Gloucestershire YST gives telephone advice to frontline officers and can share information about any children involved in an incident, and whether any social workers or other agencies are involved with the child. Not all the officers we spoke to were aware the YST offered this support to them on the street. The YST also told us officers don’t contact them as much as they could. But those officers who had contacted the team said the support works well.

Frontline officers can refer children who admit their offence to the Children First scheme (see section 1: Leadership, accountability and partnerships) to help prevent further offending behaviour. A panel with representatives from the police and other services decides how the child should be dealt with. Where appropriate, children can be referred to the scheme from the street, which diverts them away from custody.

The force has made progress in diverting children from custody. The number of children entering custody has reduced over the last three years. Sometimes the seriousness of the offence, or managing the risk to the child or others, leaves no alternative other than arrest. In the cases we examined, it was difficult to see how custody could have been avoided.

Support for frontline officers dealing with people with mental ill health isn’t always good enough. The force and the mental health services it works with have recently re‑introduced their triage car scheme. (This had stopped operating due to staffing pressures caused by COVID-19.) A police officer and a mental health professional give advice and assistance to officers and attend incidents if needed. The scheme’s working hours are very limited, although there are plans to increase them.

Not all the frontline officers we spoke to knew the triage car was available again. But they spoke positively of the service from when they had used it previously. They greatly value the support it offers them, especially when deciding if a person needs to be detained under section 136 of the Mental Health Act 1983.

Frontline officers said they would contact the mental health crisis team for advice when deciding what to do when a person is in mental health crisis. They are generally able to speak to a mental health professional. But they said the advice they receive doesn’t always give them the reassurance they need. This sometimes means they detain the person under section 136 as a way of managing the risks the person poses to themselves or others, rather than considering a health-based option.

Frontline officers should take section 136 detainees to the mental health suite (the health-based place of safety) in an ambulance. But long waits for ambulances often mean they use police cars. Once at the mental health suite, there is sometimes a long wait before they can hand the person over for a Mental Health Act assessment. This is poor use of police officers’ time and a poor outcome for the person in mental health crisis.

Officers don’t take people detained under section 136 to custody as a place of safety. Officers told us that when they attend an incident because an offence has been committed, they usually arrest the individual unless it is clear the person is in mental health crisis. The investigation into the offence continues while any suspected mental ill health concerns are dealt with in custody. This is stopped or paused if a Mental Health Act assessment determines that the person needs to go to a mental health facility.

Officers normally take detainees to custody in police vans. Otherwise they use police cars.

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

Expected outcomes (section 3)

Detainees receive respectful treatment in the custody suite and their individual needs are reflected in their care plan and risk assessment. Detainees are informed of their legal rights and can freely exercise these rights while in custody. All risks are identified at the earliest opportunity.

Respect

Custody staff interact respectfully with detainees, but some custody practices are disrespectful and don’t adequately protect the dignity of detainees. Force guidance allows for detainees to be left naked in their cell to “mitigate risk of self-harm”. This practice is disrespectful, and although staff told us it happens rarely, it should cease (see section 1: Leadership). The routine removal of footwear and failure to give replacements means some detainees walk around custody in their socks. Detainees generally have to request toilet paper rather than it being offered (see areas for improvement under Detainee care).

The large booking-in area benefits from natural light. Desks are of a suitable height, but detainee privacy can’t always be maintained. Conversations between custody officers and detainees, which may involve sensitive information, can be overheard. The area can also become noisy. This limits effective communication and further compromises confidentiality when custody officers deal with some detainees. A separate discreet booking-in area is available, but staff don’t routinely use it for sensitive matters.

Most detainees are told that CCTV operates in the suite and that cell toilets are obscured from view. The two cells identified as search rooms can’t be viewed on monitors, so detainee dignity is protected. Shower areas are sufficiently private. But there are only two signs explaining that CCTV is used in the suite, both in the booking-in area.

Meeting diverse and individual needs

Custody staff recognise and generally do their best to meet individual and diverse needs.

The custody suite is adequately equipped to help detainees with physical disabilities. Adjustments include:

• a separate booking-in room with a lowered desk;
• an accessible cell with a lowered sink and some appropriately placed call buttons that people can use to summon help;
• step-free exercise yards;
• an adapted shower and toilet facility;
• a hearing loop fitted in the booking-in area;
• coloured bands in cells and on corridors to help detainees with sight impairments;
• thicker mattresses to raise the height of cell benches for those who struggle with mobility; and
• a readily available wheelchair and walking frame.

There is, however, no information in Braille. And not all staff are aware of easy read rights and entitlements, although we sometimes saw easy read documents being given out during the inspection.

Custody staff have some awareness of neurodivergent conditions. Some are aware that distraction activities and equipment such as headphones can help neurodivergent detainees cope better in custody. Apart from saying they would secure an AA or make a referral to the mental health L&D team, most staff couldn’t describe other actions they would take to improve the experience for detainees with these needs.

Women are told during booking in that they can speak to a member of staff in private. They aren’t routinely allocated a female member of staff, and on the rare occasions this happened, there was little meaningful interaction as a result. On arrival, women are asked if they have any menstrual care needs, but after this they need to ask, as staff don’t routinely check whether they need anything. A good range of feminine hygiene products is available, but disposal arrangements rely on custody staff taking used products away, which is unsatisfactory.

When detainees speak little or no English, there is good use of the telephone interpreting service during booking in. But the force doesn’t frequently use it for other important custody processes, such as reviews of detention and release. This potentially limits detainee understanding. Telephones used for interpreting are mostly used on loudspeaker, which reduces privacy for detainees. Custody staff can access rights and entitlements leaflets in different languages, but they don’t consistently give detainees written information in a language they understand.

Staff routinely ask detainees if they have any religious needs and detainees can continue to observe a faith while in custody. Qibla markings, indicating the direction of prayer for Muslim detainees, are clearly marked in all cells. The force stores its range of religious books and items respectfully, but it caters only for those following Christianity or Islam.

Custody staff have good awareness of the needs of transgender detainees. Some have had direct experience of working with transgender detainees in custody, and all described appropriate treatment of them.

Risk assessments

The identification of risk is generally good, but the management of it requires some improvement. Detainees are usually booked in promptly, but when it is busy there can be a long wait in holding rooms before their detention is authorised. When queues form, there is little management to triage risks or to prioritise children or vulnerable detainees for booking in.

When completing initial risk assessments with detainees, custody officers focus appropriately on identifying risks, vulnerability factors and welfare concerns. They interact positively with detainees to complete the risk assessment, and they ask relevant additional and probing questions when required. They routinely cross‑reference with force computer systems and the Police National Computer warning markers to help identify risk factors. Custody officers generally ask arresting and escorting officers if they have any relevant information to contribute.

When several custody officers are on duty, it is clear who the designated custody officer for each detainee is. This information is documented on records.

Observations are generally set at a level commensurate with presenting risks. But not all detainees under the influence of alcohol and/or drugs are monitored at a level that means they need to be roused. This is required by Level 2 in the College of Policing’s APP – Detention and Custody and presents a significant risk. Detention officers rouse those on Level 2 in the right way and record this accurately. But staff sometimes reduce these observation levels too quickly, with poor justification for those decisions recorded.

Staff check detainees at the required frequency. And they accurately record the times of checks in detention logs. But entries aren’t always clear due to the pre-populated text that is used. Also, different detention officers complete the checks, meaning they might not pick up changes in a detainee’s behaviour or condition. These practices don’t follow APP guidance.

When the assessment indicates a heightened level of risk, staff observe detainees at either Level 3 (constant observation on CCTV) or at Level 4 (physical supervision at close proximity). Custody officers adequately brief staff conducting these duties, but custody records rarely include details of the briefing or the identity of officers involved, which doesn’t follow APP guidance.

Regardless of presenting risks, as in our previous inspection, custody staff continue to routinely remove clothing with cords from detainees, as well as footwear, rather than making an individualised risk assessment. This doesn’t follow APP guidance. Staff don’t always document when clothing has been removed or record any justification for it.

There remains no collective handover between the incoming and outgoing custody staff to ensure all relevant information is passed on to those taking over responsibility for detainees. The content of handovers is properly focused, but staff on duty don’t share the information well enough between them. Custody officers hand over separately to their incoming peers; detention officers conduct their handover as a team, with no custody officer involvement. HCPs are generally on duty but aren’t involved in the handovers. After receiving the handover, custody officers don’t consistently visit detainees in their care. When they do, they don’t always speak to or otherwise engage with detainees. Again, these practices don’t follow APP guidance.

Cell call bells are audible and staff generally respond to them promptly via an intercom system. Not all custody staff carry anti-ligature knives. This is poor practice, which compromises detainee safety as it limits their ability to respond immediately if needed when entering a cell.

The management and control of cell keys is poor. They are sometimes handed to non-custody staff (contrary to the force custody manual), which diminishes the control custody staff should maintain over detainees and others in the suite.

Individual legal rights

Detainees are generally booked into custody promptly. Some wait if the suite is busy.

Custody officers appropriately authorised detention. Arresting officers give detailed circumstances of arrest and good explanations of why detention is necessary. Custody officers are confident to refuse detention if it doesn’t meet the necessity and proportionality criteria (PACE Code G).

The force uses voluntary attendance well to divert people from custody when appropriate. Officers encourage voluntary attendance interviews, and the force has good facilities across its area to carry out these interviews so voluntary attendees don’t have to enter the custody area – unless biometrics need to be taken.

Generally, custody officers try to make sure cases are progressed as soon as they can be. But delays can happen due to waiting for solicitors or AAs to attend. The force was unable to give us accurate information on average lengths of detention for detainees. But our analysis of custody records for the week immediately before our inspection suggests that detention times were reasonable, although longer at the weekends.

Information given by the force shows the number of immigration detainees entering custody is reducing. They spend an average of 21 hours and 24 minutes in custody – although this is not broken down to show how long they are there after they are served with their IS91 immigration papers (at which point immigration services should transfer them to an immigration facility).

Custody officers give good explanations to detainees about their right to have someone informed of their arrest, and their right to consult a solicitor and access free independent legal advice. But they don’t always tell detainees they can read the PACE Code C booklet (recent edition August 2019). Photocopies of the booklet are available in the suite, but staff don’t routinely show and offer them to detainees. During our inspection, copies were placed at each booking-in desk to remind custody officers to offer them to detainees when giving their rights and entitlements.

The custody suite has plenty of copies of the rights and entitlements leaflet, which details detainees’ individual rights, entitlements, treatment and care while in custody. But staff don’t always hand this leaflet to detainees. The easy read version of the rights and entitlements leaflet is also available, but again, staff don’t always hand it to children or vulnerable adults, who would benefit from them. This doesn’t meet the requirements of PACE Code C paragraph 3.2.

Posters in different languages advertising the right to free legal advice aren’t displayed at any of the booking-in desks, as required by PACE Code C paragraph 6.3.

None of the custody officers we spoke to were aware of the requirements of PACE Code C Annex M, which requires important custody documents and records to be translated into a language that the detainee understands.

There are enough interview and consultation rooms for detainees to consult their legal representatives in private. Those wishing to speak to their legal representative on the telephone can also do so privately. Legal representatives are given a summary printout of the front sheet of their client’s custody record on request.

Custody officers know how to contact the relevant embassies, consulates or high commissions for foreign nationals coming into custody if detainees request this, or if notification is required. We saw cases where officers proactively did this.

Staff clearly explain to detainees what happens to any fingerprints, photographs and DNA that they take, and how these are dealt with and disposed of, if appropriate. The storage of DNA samples in freezers is in line with current guidance, but they are not held securely to ensure sample integrity.

Reviews of detention

Reviews of detention aren’t always carried out well or in the best interests of the detainee. The force isn’t always meeting the requirements of PACE and its codes of practice, which is a cause of concern.

Many reviews are carried out early and often grouped together. They don’t always note the reason why they are early on the custody record.

We didn’t see staff carry out any reviews by telephone, which is positive. But they do conduct many reviews while the detainee is asleep. We found some cases where the reviews took place outside recognised rest periods and the detainee should have been woken. When this happens, detainees are rarely informed or asked at the earliest opportunity if they want to make any representations. This is required by PACE Code C paragraph 15.7.

During the reviews we observed, staff treated detainees courteously. They reminded detainees of their rights and entitlements and discussed their basic welfare. But in many of the reviews, detention was authorised before giving the detainee – and their AA or their legal representative when present – the opportunity to make any representations. This doesn’t meet the requirements of PACE Code C paragraph 15.3. In some reviews, the detainee wasn’t told that their continued detention was being authorised.

In one case, a child was in custody for just over 7 hours but didn’t have their detention reviewed, which is a breach of section 40 of the Police and Criminal Evidence Act 1984 (PACE).

Recording of reviews of detention is inconsistent and sometimes poor. This makes it difficult to assess whether they are conducted properly and in the interests of the detainee.

Access to swift justice

Access to swift justice for detainees needs to be better. Many detainees are waiting too long for their cases to be completed.

Our custody record analysis showed 52 percent of cases were finalised during the first period of detention. The remaining detainees were bailed or released under investigation.

The force has governance processes to monitor suspects who are bailed. One dedicated officer manages this across the force, ensuring appropriate scrutiny and control. Case numbers appear to be manageable and data is readily available.

The force doesn’t have the same scrutiny or control over cases where the detainee has been released under investigation (RUI). At the time of the inspection, the force told us it had 2,484 RUI cases – a large proportion of which are more than 6 months old. The force is introducing a closure team to manage and progress these cases better.

Staff give detainees notices when they are released under investigation, outlining the possible offences they may commit if they interfere with victims or witness while the investigation is ongoing. Custody officers usually also give verbal explanations.

Complaints

Detainees can make a complaint while in custody. Custody staff are clear on the procedure to follow. We saw staff offering some detainees the opportunity to complain.

But posters explaining to detainees how they can make a complaint while in custody are not prominently displayed in the suite.

Section 4. In the custody cell, safeguarding and health care

Expected outcomes (section 4)

Detainees are held in a safe and clean environment in which their safety is protected at all points during custody. Officers understand the obligations and duties arising from safeguarding (protection of children and adults at risk). Detainees have access to competent healthcare practitioners who meet their physical health, mental health and substance use needs in a timely way.

Physical environment is safe

The custody facilities in Gloucestershire comprise one full-time designated suite at Quedgeley, with 50 cells across 4 separate wings.

General conditions in the suite are good. Cells are well maintained but are only superficially clean. There is some natural light in all cells and no evident graffiti. There are potential ligature points in the suite due to the design of toilets. We gave the force a comprehensive illustrative report detailing the general conditions we found during the inspection. They acted upon this and told us they had arranged a programme of deep cleaning for each wing.

A good-quality CCTV system is installed covering all areas of the suites, including all cells – although there are few signs to tell detainees this.

The suite should have regular daily health and safety maintenance checks, as detailed in the force custody manual. But custody officers don’t know this, and detention officers don’t record the outcome of them. Weekly health and safety maintenance checks are completed, as required by APP guidance. Staff told us most repairs are completed quickly.

Most custody staff are aware of emergency evacuation procedures, including how and where to evacuate detainees in an emergency. None we spoke to had been involved in a physical evacuation in the last year or more, which would make sure the procedures work in practice. Force data shows there was an evacuation drill within the past seven months, but this was abandoned shortly after commencement. The data doesn’t identify which custody staff were present or show any custody-related learning points.

Safety: use of force

Overall, when staff use force on detainees in custody, it is mostly proportionate to the risks or threats posed. But information about when and how it is used is limited. Staff don’t always complete use of force forms and the recording of use of force on custody records is generally poor. Gloucestershire Constabulary doesn’t know how often, and how appropriately, force is used. This is a cause of concern.

Officers don’t always submit individual use of force forms, as required by the NPCC guidance. We asked for use of force forms for the incidents we examined during our case audits and on CCTV. Of those we requested, less than half were provided. On some of the forms we examined, the quality of the information was poor. Use of force incidents were often not recorded on custody records. And sometimes the information recorded didn’t reflect what we saw happening on the CCTV footage. This poor level of information means it is not possible to know how often and what type of force staff use in custody.

We reviewed 19 cases of use of force on CCTV. Staff managed most incidents well. When using force in the cell, the custody officer supervised the officers involved in restraining the detainee. Staff mostly deployed restraint techniques correctly, in a way that was necessary and proportionate to the risk or threat posed.

We saw some good examples of officers de-escalating situations well through good communication and negotiation with the detainees. This avoided the need to use force.

In some cases, staff forcibly removed detainees’ clothing to replace it with alternative clothing. They paid good attention to maintaining the detainees’ dignity when removing clothing, but they didn’t always clearly record the justification for it.

We referred one case to the force for learning. The detainee was restrained in limb restraints and handcuffs for a considerable period of time, and the justification for using this restraint technique was unclear.

There is little quality assurance of use of force incidents that take place in custody. Custody supervisors don’t regularly review incidents, and there is no policy requiring them to do so. Any reviews that do take place are usually because of a complaint or a request, for example, from a legal representative.

We saw some detainees arrive without handcuffs. But when detainees are handcuffed, staff don’t normally remove the handcuffs until the detainee is at the booking-in desk – despite guidance that they can be removed from compliant detainees in the holding cells if there are no risks. Sometimes, when detainees are queuing to be booked in, they are held in handcuffs unnecessarily and for too long.

Once at the custody desk, staff usually remove handcuffs quickly. They record when handcuffs are used, and sometimes if any injuries are caused. But staff don’t always record the reasons for the use of handcuffs and the time that they are removed.

We saw few strip searches during the inspection. Staff don’t always ensure the privacy of these searches as they sometimes leave the doors to the rooms where they are carried out open. Staff don’t always adequately record the justification for and conduct of the search, as required by PACE Code C Annex A. This was a concern in our previous inspection. It contributes to our cause of concern in this inspection that the force isn’t consistently meeting the requirements of PACE and its codes of practice.

Custody officers and detention officers are up to date with their personal safety training and a rolling programme of refresher courses is in place.

Detainee care

The approach to looking after detainees is reasonably good. Those we spoke to were positive about the care they received, although some less so about access to facilities during their stay.

With the exception of food and drinks, custody records we examined showed few offers or provision of any other detainee care. And our observations showed limited provision in practice. This was also the subject of some formal complaints.

The main food preparation area is clean and tidy, but the microwave used to heat meals is dirty. The range of food, including microwaveable meals, porridge and cereal bars, meets most dietary requirements and is offered frequently, along with drinks of tea, coffee, water or squash. Petty cash is available to buy food for detainees for whom custody food is unsuitable. Signs on in-cell sinks advise that the water isn’t suitable for drinking.

Most cells have toilets, but detainees are generally only given toilet paper on request. Unwrapped rolls of toilet paper are often stored on door handles, which is unsanitary. No soap or paper towels are provided for in-cell handwashing. Showers are in good condition, and towels and a range of toiletries, including vegan-friendly products, are available. We saw few detainees offered or given an opportunity to wash or shower, including those who were held overnight or those attending court. On the occasions we saw detainees have a shower, staff gave them clean replacement clothing if requested.

Sufficient stocks of clothing are available, including jogging bottoms, T-shirts, sweatshirts and plimsolls. Paper underwear is available, but not all staff know about it, and we saw they didn’t give it when needed during the inspection. The provision of alternative footwear is inconsistent. While some detainees choose not to wear the plimsolls provided, many aren’t given replacements and walk around the suite or their cell in socks.

Most cells contain a mattress and pillow, although some are in poor condition. Some are so thin they offer little comfort. Sufficient clean blankets are available and are usually given when the detainee is taken to the cell. Additional blankets are usually given on request.

Three outside exercise areas are available for use by detainees to access fresh air. Following an individualised risk assessment, staff can leave detainees unsupervised. Although we saw some use of these outside areas, staff don’t often proactively offer detainees the chance to use them.

A range of reading material is available, including a small number of books in different languages. Although we saw a few detainees with reading materials, staff don’t always proactively provide them.

A small supply of other distraction activities are available, including colouring books/pencils, puzzles and stress balls. But, as with other provisions, staff rarely offer them to detainees. Some staff told us they are reserved mainly for children.

There is a visiting room, which is positive. It is not often used, but some custody staff described situations when visits from family and friends would be allowed, such as for people who have been recalled to prison.

Safeguarding

The officers we spoke to understand their responsibilities to safeguard children and vulnerable adults. Arresting officers told us they submit safeguarding referrals (through the vulnerability identification screening tool (VIST)) for all children they take to custody, and when needed for vulnerable adults. Custody officers can also complete a referral to make other agencies aware when they identify safeguarding concerns during custody.

Gloucestershire YST supports children in custody. The team works from 9.00am to 9.00pm. The workers have their own room in the custody suite, where they assess children and make safeguarding referrals and arrangements if needed. We were told they share information with custody officers to help them care for the child while in custody and release them safely. L&D workers based in custody give further advice and help if there are concerns about the child’s mental health.

But there is little recording on custody records to show how the YST has been involved or any actions it has taken.

Children and vulnerable adults don’t always receive support from AAs quickly enough to help them understand their rights, entitlements and custody processes. Custody officers try to find parents, other family members and care or support workers to act as an AA in the first instance. We found some cases where early contact was made, and AAs arrived promptly. But sometimes there were delays in staff contacting an AA, or an AA was unable to attend promptly. In these cases, detainees waited a long time before an AA arrived.

When family or care workers aren’t available or able to act as the AA for the detainee, custody officers arrange an AA through the Caring for Communities and People (CCP) scheme. The scheme uses volunteers and can be contacted between 9.00am and 10.00pm. The volunteers attend custody until 11.00pm but will stay if already there and if the detainee’s case can be dealt with. Outside these times, detainees wait.

CCP generally only provides an AA for the time of the interview. Staff carry out the re‑reading of rights and entitlements and other custody processes, such as fingerprinting, at this stage. Sometimes an AA is not available to attend. The detainee either waits until one is available, is RUI or is bailed to return for interview at a later stage.

Overall, the arrangements for making sure children and vulnerable adults consistently receive support from an AA promptly are not good enough.

Custody officers assess whether an adult who may be vulnerable needs the help of an AA. The force has recently issued the College of Policing guidance tool (known as ID CURE) to help custody officers make these assessments in a more consistent way. But at the time of inspection, staff were not routinely using it.

When there is some doubt as to whether a detainee needs an AA, custody officers may ask the healthcare practitioner or an L&D worker for advice. While this is an appropriate action to take, if the advice is not readily available it can lead to significant delays before a decision is made. If it is decided the detainee needs an AA, there are further delays while staff arrange one.

Recording on custody records about when staff request AAs, when they arrive and their relationship with the detainee is generally poor. There is no information to show how long children and vulnerable adults wait before they receive support from an AA. The force doesn’t know how well it is meeting the needs of children and vulnerable adults.

Custody officers give good explanations about the role of an AA to those who don’t know about it. There is also written guidance to help them, but they don’t always give it out.

The force generally cares well for children in custody. Where possible, custody officers place them in cells in the quieter areas of the suite. Distraction activities such as puzzles, crayons and stress balls are available, and we saw some children using them. Parents or those acting as AAs are not normally allowed to sit with children in the visits room or in their cells, but staff told us this could happen if it was necessary for the child’s welfare. We found a case where a mother spent some time with her daughter in the cell.

We saw custody officers speaking with children in a way that was suitable for their needs. They clearly explained their rights, entitlements and what would happen to them during their time in custody.

But some areas need improving. Easy read versions of the rights and entitlements are available, but staff don’t routinely give them to children. Girls aren’t always assigned a female officer or member of staff to oversee their welfare in custody, as required by section 31 of the Children and Young Persons Act 1933.

Custody officers closely scrutinise the need to authorise the detention of children. They also try to minimise the time a child stays in custody. Where appropriate, they use bail or RUI to avoid overnight detention. In one case we examined, officers released a child on bail to avoid overnight detention because there was no AA to attend for interview. But we found some children spend a long time in custody. Sometimes this is because of delays in an AA arriving or because it is not possible to return the child home safely.

Custody officers, the YST and children’s social services discuss the best way of dealing with a child in custody. But little information is recorded about these discussions to show what actions they take and what decisions they make as a result.

Children charged and refused bail should be moved to alternative accommodation arranged through the local authority. (This is the local authority’s statutory responsibility.) The force’s information shows that 18 children were charged and remanded in the year from 1 February 2021 to 31 January 2022. The force made eight requests to the local authority for secure accommodation and five for appropriate (non-secure) accommodation. But only two children were moved – both to appropriate accommodation. In one of the other cases, the child didn’t need accommodation because they went straight to court. In the remaining cases, there was no record of requests being made.

Custody officers told us it is very rare for other accommodation to be provided. They usually discuss each case with children’s social services to agree the best options for the child, but the area has no secure bed spaces, and only one appropriate (non-secure) bed space. This means most children aren’t moved as they should be. There was little recording of any discussions on the custody records we examined, but in some cases juvenile detention certificates were completed. These indicated discussions had taken place.

There is a joint agency protocol for transferring children into local authority accommodation from police custody. This sets out local processes to follow, including escalation procedures. Children who are charged and refused bail are monitored at quarterly meetings attended by the chief inspector of custody and the head of the Youth Strategy Team. But outcomes for these children remain poor.

Governance of health care

G4S Health Services gives detainees physical healthcare support and carries out forensic testing. HCPs are based in the custody suite 24 hours a day. HCPs and police staff have good access to forensic medical examiners (FMEs), who are on call 24 hours a day. Gloucestershire Health and Care NHS Foundation Trust also gives mental health L&D support seven days a week.

Partnership working between health services and police staff is very good. Effective contract monitoring takes place monthly and regular clinical governance meetings inform clinical practice. A dedicated senior officer from the force oversees health activity and a senior lead HCP oversees clinical activity.

Physical healthcare services are fully staffed and any short-term gaps are adequately covered by the on-call FME, who attends the suite if necessary. HCP response times are graded according to clinical and forensic need, and data supplied by G4S shows response times are met in over 96 percent of referrals. All custody staff and patients we spoke to report a very responsive health service in the suite.

HCPs are experienced and include nurses with emergency department and primary care experience, along with paramedics. Induction processes for new staff are competency based and cover the required standards to work autonomously. Arrangements for clinical and managerial supervision are in place, but individual supervision isn’t formally recorded. Staff receive an annual performance appraisal and mandatory training compliance is excellent. The clinical lead runs a 30-minute virtual ‘custody safety pause’ session 3 times a week, which allows HCPs to share information and access peer support.

There is a separate, well-advertised health complaints procedure and adequate arrangements to report clinical incidents. There are also arrangements in place for sharing any associated learning.

The clinical area in the suite is clean, well ordered and meets infection-prevention standards. There are two separate forensic-sampling areas. Clinicians have access to the necessary equipment, including PPE.

HCPs have access to standardised emergency equipment, including a defibrillator, which comply with national standards. We found some gaps in the recording of critical daily safety checks. This requires attention. Custody staff have access to further life-saving equipment, which is readily available in the suite.

Patient care

Staff we met showed excellent knowledge of health care in custody and an experienced HCP leads the service well. All custody staff we spoke to valued health services and commented very positively about the care they deliver.

Clinical records we looked at show the care and treatment offered is appropriate to patient need and, despite being paper based, they are stored securely. HCPs, with patient consent, can access NHS summary care records to verify current treatment plans. HCPs now share clinical risks and important treatment issues appropriately and concisely directly onto the electronic custody record. (This is an improvement since our previous inspection.)

We observed several patient consultations, which were respectful and professional. Staff conducted them in private, using established protocols for gaining patient consent. All patients we spoke to in the suite were happy with their care and treatment.

Medicines management is generally safe and appropriate for patient care. Stocks of medicines are held securely, but the provider needs to make sure daily stock checks are carried out and recorded accurately. Patients can receive prescription medicines, including community-prescribed opiate substitution treatment. Patients’ own medicines are held securely with their personal property. Well-established, evidence-based protocols are used to provide symptomatic relief for detainees experiencing acute alcohol and drug withdrawals. Custody staff can administer nicotine replacement products, which is good.

Substance misuse

Support for detainees with needs relating to substance misuse is reasonable. There is currently no substance misuse practitioner working in custody, but the local provider of this service is recruiting for a practitioner to be in custody five days a week. The L&D team offers signposting and referral to community services in the absence of a substance misuse practitioner.

L&D staff have strong links with community services to share information. After detainees are released, support, time and recovery (ST&R) workers offer them support in attending appointments and accessing any help they need.

On leaving custody, staff give detainees information including details of community‑based substance misuse services, but there is no immediate access to sterile injecting equipment.

Mental health

An experienced L&D team offers an excellent service to detainees with all types of vulnerability. Staff are based in the custody suite five days a week and on call for support at weekends. The extensive experience and diverse skills within the team have led to strong working relationships with both the police and local agencies to offer a wide range of support options to detainees. There is robust management and governance of the L&D service, with the team describing excellent and supportive leadership.

ST&R workers are based in custody five days a week, offering a comprehensive support service to all detainees who require their help, as well as follow-up support in the community. The team offers detainees support using a screening tool to document the outcome of each intervention. ST&R workers finish at 3.00pm and don’t work weekends, so detainees arriving later in the day or at weekends don’t receive the same service as those arriving before 3.00pm Monday to Friday. The ST&R team contributes to release planning arrangements with custody staff.

A nurse is on call seven days a week to see detainees presenting with more complex needs. Custody staff or ST&R workers can refer detainees to the nursing team. Staff told us the nursing team is responsive and supportive. Specialisms within the nursing team include learning disabilities, social work, forensics and mental health.

There are specific schemes to support women and veterans. The Nelson Trust is on call five days a week to see women in custody. The trust has also set up a veterans’ scheme, which detainees may be referred into.

The YST offers advice and assistance to help divert children from custody or give specialist support in the custody suite. The YST is on call to see children in custody six days a week. It offers phone advice to custody staff and frontline officers seven days a week. In the YST’s absence, or if urgent needs are identified, the L&D team sees children and refers them to the appropriate agencies for onward support.

All L&D staff have access to local community mental health records, helping them give continuity of care. And staff can promptly access information they need from outside the local area. Currently the team doesn’t have access to custody records to document their interactions with detainees and only hard copies of mental health assessments completed by nurses are shared with custody staff. As a result, there is no record for custody staff to see which detainees have been seen. And there is no way for the L&D staff to document the sharing of risk information with custody staff. Plans had been in place to enable access, but these were put on hold because of the pandemic.

Access to out-of-hours support is good for detainees. HCPs call for a Mental Health Act assessment if they identify concerns. Both the L&D team and custody staff speak highly of the telephone support available to them from the approved mental health professional (AMHP) hub, and they don’t experience delays when they call AMHPs into custody. But neither the force nor the AMHP service captures any data to monitor out-of-hours activity.

According to police and L&D staff feedback, when detainees are assessed under section 2 of the Mental Health Act 1983 as needing transfer to a mental health bed, they are rarely moved because no bed is available. This leads to the force detaining them under section 136 of the same Act so they can leave custody and be taken to a health-based place of safety. The force doesn’t collect information to show how often, or in what circumstances, this happens. The L&D team manager and the police sergeant leading on mental health in custody have developed a comprehensive local policy and flowchart, which clearly set out the escalation process and the options staff can follow in these circumstances.

There is a street triage scheme, consisting of a police officer and a mental health professional who give advice and assistance to officers and can attend incidents. The scheme stopped at the start of the pandemic but has recently been re-instated. However, its working hours are limited. Officers value the street triage car highly as a way of reducing the number of people with mental ill health being detained under section 136 or brought into custody.

Section 5. Release and transfer from custody

Expected outcomes (section 5)

Pre-release risk assessments reflect all risks identified during the detainee’s stay in custody. Detainees are offered and provided with advice, information and onward referral to other agencies as necessary to support their safety and wellbeing on release. Detainees appear promptly at court in person or by video.

Pre-release risk assessment

The force has a clear focus on making sure it releases detainees safely. We saw some good attention and care given to detainees on release.

Custody officers engage well with detainees to complete pre-release risk assessments. They use initial risk assessments and care plans appropriately to make sure they address or reduce any risks identified. Relevant agencies, such as the L&D team, are involved when necessary. But some custody records don’t have enough detail and don’t reflect practice.

Detainees who don’t have the means to get home safely can make telephone calls to arrange transport. They can also access bus and train tickets. Police officers take vulnerable adults home if there are no other suitable means available, and children when they can’t release them into the care of a responsible adult.

Leaflets containing information about both national and local support agencies are available, but staff rarely give them to detainees on release. They are only available in English.

Detention officers complete digital person escort records (dPERs) and book transport for detainees attending court and those who have been recalled to prison. The dPERs aren’t always well completed and are often missing relevant information, including medical details. Custody officers don’t check the content and detention officers sign them off without custody officers approving them. This is contrary to the College of Policing’s APP – Detention and Custody guidance.

Custody officers don’t speak with detainees transferring to court or recalled to prison when carrying out pre-release risk assessments. They document the assessments so the custody record can be closed. But without officers speaking to the detainee, we can’t be confident the force has properly identified risks before the detainee’s transfer, or addressed or mitigated them. It is misleading and doesn’t follow APP guidance.

Courts

Working practices have improved since our last inspection. The force makes sure that once detainees are remanded, they are generally presented before the first available court. This means most aren’t held for any longer than necessary.

Detainees remanded for court are generally collected promptly in the morning, although there are sometimes delays if transport isn’t readily available. The local magistrates’ court doesn’t directly accept those arrested on warrant during the day, so they are booked into police custody. Staff say there is some flexibility with the court, which often accepts detainees later in the afternoon either to appear in person or through a video link, which minimises their time in custody.

The video link is primarily available to hear cases virtually if a detainee is suspected or confirmed of having COVID-19, avoiding any unnecessary travel. This manages and minimises the risk of infection transmission.

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

Causes of concern and recommendations

Areas for improvement

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 through their time in custody to their release. Our inspections are unannounced, and 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

An analysis of custody records is carried out on a representative sample of all records opened in the week preceding the inspection in all the suites in the force area. Records analysed are chosen at random. A government statistical formula with a 95 percent confidence interval and a sampling error of 7 percent is used to calculate the sample size. This makes sure that our records analysis reflects the throughput of the force’s custody suites in that week. The analysis focuses on the legal rights and treatment and conditions of the detainee. Only statistically significant comparisons between groups or with other forces are included in the report.

A statistically significant difference between two samples is one that is unlikely to have arisen by chance alone and can be assumed to represent a real difference between the two populations. To adjust p-values for multiple testing, p<0.01 was considered statistically significant for all comparisons. This means there is only a one percent likelihood that the difference is due to chance.

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, vulnerable people, individuals with mental health problems, and where force has been used on a detainee.

The 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 Police and Criminal Evidence Act (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 staff

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

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

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

Focus groups

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

Feedback to force

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

Appendix II: Inspection team

• Norma Collicott: HMI Constabulary and Fire & Rescue Services inspection lead
• Patricia Nixon: HMI Constabulary and Fire & Rescue Services inspection officer
• Ramzan Mohayuddin: HMI Constabulary and Fire & Rescue Services inspection officer
• Marc Callaghan: HMI Constabulary and Fire & Rescue Services inspection officer
• Ian Smith: HMI Constabulary and Fire & Rescue Services inspection officer
• Kellie Reeve: HMI Prisons team leader
• Fiona Shearlaw: HMI Prisons inspector
• Shaun Thomson: HMI Prisons health & social care inspector
• Dayni Johnson: Care Quality Commission inspector
• Joe Simmonds: HMI Prisons researcher
• Alec Martin: HMI Prisons researcher

Fact page

Note: Data supplied by the force.

Force

Gloucestershire Constabulary

Chief constable

Rod Hansen

Police and crime commissioner

Chris Nelson

Geographical area

Gloucestershire

Date of last police custody inspection

27 April – 1 May 2015

Custody suites

Compass House, Quedgeley: 50 cells

Annual custody throughput

7,090 in 2021

Custody staffing

• 1 superintendent (for both criminal justice and custody)
• 1 chief inspector custody
• 2 criminal justice inspectors
• 15 custody sergeants
• 4 lead detention officers
• 28 detention officers

Health service provider

G4S

Back to publication

Report on an unannounced inspection visit to police custody suites in Gloucestershire