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

Summary

This report describes our findings following an inspection of Warwickshire Police custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and HM Inspectorate of Prisons (HMIP) in September 2021. 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 safe detention and the respectful treatment of detainees, with a particular focus on vulnerable people and children.

This inspection of custody facilities took place during the COVID-19 pandemic. To manage ongoing risks as the pandemic continues, we adapted our methodology to carry out some of our activities remotely and minimise our physical presence in the force and its custody suites. To achieve this, we gave the force more notice than usual of the inspection. Our interviews and focus groups were carried out remotely. Our observations were carried out 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 Warwickshire Police in 2014. At that time Warwickshire provided its custody services in collaboration with West Mercia Police. Our recommendations applied to both forces, but for this inspection we have assessed Warwickshire’s progress against them. Of the 29 recommendations made during that previous inspection, Warwickshire has achieved or partially achieved 15 of them. Two recommendations are no longer applicable, but the remaining 12 have been identified in this inspection as areas still requiring attention.

To aid improvement, we have made three recommendations to the force (and the police and crime commissioner) addressing the main causes for concern, and have highlighted an additional 22 areas for improvement. These are set out in section 6.

Leadership, accountability and partnerships

We last inspected Warwickshire Police’s custody arrangements in October 2014, when it was formally collaborating with West Mercia Police under section 22 of the Police Act 1996. This arrangement ceased in 2019. Since then Warwickshire Police has improved its oversight of its custody provision. It also has a clear governance structure for the safe and respectful provision of custody services that supports their continued improvement. However, progress since our 2014 inspection has been limited in some areas.

The force isn’t always deploying its staff effectively to provide the best outcomes for detainees. When the custody suites operate at minimum staffing levels, with only one custody officer on duty, it sometimes leads to delays for detainees. Some of the tasks that detention officers should do are being carried out by custody, arresting or investigation officers. Local policing inspectors carry out reviews of detention, but these are sometimes too early, rather than at the specified times for review. This is because inspectors fit them in around their commitments outside custody.

The force doesn’t always meet the requirements of the Police and Criminal Evidence Act 1984 or follow its codes of practice – mainly when doing reviews of detention. This leads to reviews being carried out inconsistently, and not in the interests of the detainee. The force has adopted the College of Policing’s Authorised Professional Practice (APP) and additionally has its own local custody policy, but again these are not always followed. Both are a cause of concern.

The force monitors custody performance, but some important information is missing, and this hinders the effectiveness of the monitoring. Information on the use of force is not always accurate or sufficiently detailed, which means the governance or oversight of the force used on detainees in custody is not comprehensive enough. Information on ethnicity and other protected characteristics is also limited, and doesn’t show whether outcomes for all detainees are fair and equitable.

The quality of recording on custody records is inconsistent. It is often poor and doesn’t provide some of the information needed to monitor performance or show the outcomes achieved for detainees. There is little quality assurance or assessment of the standard of custody records. The standard we saw is a cause of concern.

The force is open to external scrutiny. It responds well to feedback and to any concerns raised by independent custody visitors.

The force has a clear strategic priority to divert children and vulnerable people away from custody, and works well with bodies such as the Youth Offending Service in trying to achieve this.

Pre-custody: first point of contact

Frontline officers understand the importance of diverting children and vulnerable people away from custody. Children are only taken into custody as a last resort. The mental health triage scheme helps officers to avoid detaining people who have mental ill health.

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

Custody staff speak courteously and respectfully with detainees, taking the time to explain processes and to put detainees at ease. Privacy for detainees is limited, mainly due to the design of the custody suites, and some custody procedures don’t protect their dignity. Custody staff do their best to meet the diverse needs of detainees, but with mixed success, as they are hindered by a lack of facilities and equipment.

Custody officers generally identify detainee risks well and set appropriate observation levels. But there are significant weaknesses in the continued management of risks. Detainees under the influence of alcohol or drugs are often taken off rousal checks too quickly, and observations by detention officers are not always carried out in the correct way. Some of the risk management working practices don’t follow APP guidance and don’t ensure the safety of detainees. This is a cause of concern.

Detainees entering custody have their detention appropriately authorised. But some have a long wait before they are booked into custody, and some detainees spend a long time in custody – possibly longer than necessary. Custody officers don’t always have time to check that investigations are proceeding as quickly as possible.

Custody officers give good explanations to detainees about their rights and entitlements and give detainees rights and entitlements leaflets setting this information out. However, we have some concerns that detainees don’t always understand these rights. When detainees are too intoxicated to understand their rights when entering custody, or when a detainee’s rights are withheld, it isn’t always clear if they subsequently receive an explanation of their rights or when this is given.

Detainees released under investigation receive a notice about the offences they may be committing if they interfere with victims or witnesses while the investigation is in progress. However, this information isn’t always relayed to them orally.

Detainees wishing to make a complaint while in custody are not always able to do so before they are released. The overall approach to complaints needs to improve.

In the custody cell, safeguarding and healthcare

General conditions and cleanliness in the two custody suites at Nuneaton and Leamington are good. There are potential ligature points (which could be used by a detainee to self-harm) in both facilities mainly due to the design of toilets, air vents, and some loose hatches. A comprehensive illustrative report detailing these, and general conditions, was provided during the inspection.

We assessed custody records and viewed incidents on CCTV where force had been used on detainees. In general, incidents were well handled, with good examples of officers talking with detainees to de-escalate situations and avoid using force.

Overall, the approach to looking after detainees is reasonably good. Custody staff generally have a caring attitude, and detainees spoke positively about the care they received during their stay in custody. However, some care provision could be improved.

All the officers we spoke with understand their responsibilities in relation to the safeguarding of children and vulnerable people. Appropriate adults (AAs) for children and vulnerable adults are generally secured as soon as possible, and most detainees didn’t have to wait too long before receiving support.

Most custody officers only detain children in custody where necessary. Although there is a reasonable standard of care given to children while in custody, this could be better. Custody officers they told us they try to keep children in custody for as short amount of time as possible. However, some children stay for a long time, and those charged and refused bail, although there are few of them, are not moved by the local authority as they should be.

Healthcare professionals (HCPs) provide a prompt and good standard of healthcare to detainees. All of the detainees we spoke to were positive about the healthcare they received while in custody.

The liaison and diversion (L&D) service based in the custody suites provides a high‑quality service to detainees who are vulnerable, with additional support for some groups, including children. There are good arrangements to help detainees with mental ill health, and detainees with drug and alcohol problems. This includes practical help and support in the community after the detainee leaves custody.

We were told that detainees who require an assessment under section 2 of the Mental Health Act 1983 don’t wait too long for one. However, no information is recorded to confirm this, or to show how many detainees are detained in custody under section 136 of the same Act when the assessment isn’t carried out before detainees are due to be released.

Release and transfer from custody

Custody officers identify and, as far as possible, mitigate risks for detainees before releasing them. They involve other bodies as necessary, such as housing, drug and alcohol support services. They make sure that children and vulnerable people get home safely but can’t always ensure this for other detainees.

Detention officers complete electronic person escort records (ePERs) for detainees who are attending court or who have been recalled to prison. Custody officers properly supervise the transfer of detainees to the prisoner escort and custody service (PECS).

The working practice around courts has improved from our previous inspection and now ensures detainees are presented before the first available court, meaning most are held in custody for no 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 the 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 throughout the sector and they’re 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 healthcare; 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 with staff;
• observations in suites, including discussions with detainees; and
• an examination of case records.

We also conduct a documentary analysis of custody records based on a representative sample of the custody records from all the suites in the force area open in the week before the inspection was announced. For Warwickshire Police we analysed a sample of 119 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

We last inspected Warwickshire Police custody arrangements in October 2014, when the force was formally collaborating with West Mercia Police under section 22 of the Police Act 1996. Under these arrangements the governance and oversight of custody services were shared, and some functions, such as training, were provided by West Mercia Police. These arrangements ceased in 2019.

Warwickshire Police improved the management of its custody provision following the end of the collaboration. There is a clear governance structure to monitor the safe and respectful provision of custody services and to support continuous improvement. An assistant chief constable has overall responsibility for the provision of custody services, supported by the Head of Criminal Justice and a chief inspector who is responsible for the day-to-day operation of the suites.

Governance and oversight of the health services for detainees, which is provided under contract with Mitie Care and Custody, is generally good.

There are appropriate groups meeting at strategic and operational levels to consider and discuss important areas of custody. These include:

• ‘delivering effective justice’, chaired by an assistant chief constable, which oversees all aspects of criminal justice including custody services;
• ‘investigations standards and outcomes’ and a monthly managers’ forum, both chaired by a chief superintendent, which oversee issues raised at user group meetings; and
• a custody user group, chaired by the chief inspector, which has a range of attendees including representatives from those working in custody (such as L&D services), professional standards, estates management, the independent custody visitors’ scheme, and other organisations.

Despite this, progress since our last inspection has been limited in some areas. Of the 29 recommendations made to Warwickshire and West Mercia in 2014, only 15 have been fully or partially achieved by Warwickshire Police. Therefore, many of the recommendations we make following this inspection are similar to those made previously.

The force manages its custody services in two suites based in Nuneaton and Leamington. There is a chief inspector, a custody inspector, 18 custody officers and 25 detention officers. The detention officers are employed and supervised by Bidvest Noonan. However, the force doesn’t always deploy its available staff effectively to ensure the best outcomes for detainees.

The custody suites often operate at minimum staffing levels, with only one custody officer on duty. This sometimes leads to long delays when booking detainees into custody, and to delays in other custody processes. For example, when custody officers are too busy to chase up investigations, cases don’t progress efficiently. It also means that custody officers can’t always take rest breaks.

Custody officers are not responsible for supervising detention officers, and we saw little direction given to them. Detention officers don’t perform all the tasks we would expect to see them undertake. These include, for example, searching detainees, taking detainees to their cells after booking into custody, and taking and collecting them from interview. Instead these tasks are being completed by custody, arresting or investigation officers.

Local policing inspectors are responsible for carrying out reviews of detention, but these reviews sometimes take place too early, rather than at the specified times for review. This is because inspectors fit them in around their commitments outside custody.

Initial training for staff is good. Custody officers undergo a three-week training course, and detention officers have a longer period of training. New officers shadow more experienced staff and complete a competency portfolio before they start their full duties. Training for staff is still provided by West Mercia Police, but the force is developing its own training in-house. The first course is scheduled for January 2022.

Staff reported little in the way of continuous professional development, although some of them recently went on a two-day training course, which will be repeated in 2022.

The force has adopted the College of Policing’s APP, and also has its own local custody policy. However, we observed many practices that don’t follow APP guidance, particularly those that relate to managing detainee risk. For example, not all staff were carrying anti-ligature knives and handovers between shifts didn’t involve all staff members. Force guidance is also not always followed. Detainees are sometimes put into anti-rip clothing just because they haven’t answered the risk assessment questions, which goes against force policy. We also found some inconsistent practices between the two custody suites, such as the way in which constant watch observations are carried out. These inconsistencies could lead to different outcomes for detainees who are in custody under otherwise similar circumstances.

In 2018 there was a death in custody at Leamington. The Independent Office for Police Conduct (IOPC) investigated this incident and made some learning recommendations to the force.

Accountability

The force monitors custody performance at operational and strategic custody meetings, but some important information is missing, and this hinders the effectiveness of the monitoring.

Performance information is collected and presented to show important aspects of custody provision, such as the total number of detainees held in the custody suites on a monthly and annual basis and the number of strip searches and arrests. However, there are several gaps. For example, the force doesn’t know:

• the average length of detention for detainees;
• how long detainees wait for a mental health assessment in custody;
• how many people come to police stations to be voluntarily interviewed, instead of being arrested and brought to custody; or
• how long children and vulnerable detainees wait for an appropriate adult.

There is also little qualitative information to show how well detainees are cared for in custody. The force told us it is difficult to extract some information, such as the self‑defined ethnicity of detainees, from its custody system, Athena. Without this information it is difficult to manage performance effectively.

We also found gaps in the reporting of adverse incidents, which means the force is missing opportunities to learn and to communicate good ways of working. In two cases that we examined, an adverse incident report should have been completed, but wasn’t.

Staff don’t always follow the legislation and guidance set out in the Police and Criminal Evidence Act 1984 (PACE) and its codes of practice. Some reviews of detention didn’t take place, which is a breach of section 40 of PACE. Reviews of detention for children or vulnerable detainees are often carried out by telephone, without considering and recording why these are not taking place in person. When reviews of detention take place while detainees are asleep or in interview, the detainees are not always told about them. These practices don’t meet the requirements of PACE Code C paragraphs 15.3C and 15.7, and happen often. This is a cause of concern.

There is little governance and oversight of the use of force and restraint in custody suites. Information on incidents is difficult to extract from the force’s custody system, Athena, and not enough detail is recorded on detention logs to determine what force was used, by which officers, or why it was necessary. Not all staff complete the individual use of force forms in line with the National Police Chiefs’ Council guidance. Quality assurance of the use of force is limited, which makes it difficult to confirm that when force is used, it is proportionate and justified. We could only review nine cases where force was used because CCTV footage is limited. However, overall, these cases are managed well. We referred one case back to the force as an example of a good way of working, and three cases for learning.

The quality of recording on custody records is inconsistent, often poor, and doesn’t provide all of the information needed to monitor performance or show the outcomes for detainees.

Many of the detention logs are confusing, and it is difficult to follow events in order. We saw some entries that explained why decisions had been made and the reasons for actions such as strip searches, but most detention logs lacked these details. Important information is sometimes missing, such as when detainees were informed of their rights and entitlements, when force was used on a detainee, whether risk assessments were revisited if they were not completed when the detainee was booked into custody, and when an appropriate adult was called and when they arrived. Little information is recorded to show how often or when detainees receive care such as food and drink, exercise or showers.

Pre-filled texts within the Athena custody system are used to record common tasks such as cell visits, but the comments that officers write themselves, to document their actions, often contradict them. For example, the text reading ‘cell entered, detainee roused’ is often followed by the detention officer recording that the detainee wasn’t roused. Multiple cell checks are sometimes recorded without changes to the detail for each detainee, which is poor practice.

Routine dip sampling and quality assurance of custody records is limited and doesn’t identify the concerns we have raised above. The poor recording makes it difficult to show what has happened to detainees while in custody. This is a cause of concern.

The force is unable to show that it is meeting the public sector equality duty. Staff told us they had little training about this or in managing the diverse needs of detainees.

Information about ethnicity and other protected characteristics is limited or inaccurate. Detainees are not always asked to self-define their ethnicity, and this information isn’t routinely recorded on custody records. This prevents the force from identifying any disproportionality. The force is taking steps to improve this. Although the force monitors some data to check whether outcomes for all detainees are fair, this assessment is hindered by incomplete or inaccurate information.

The force is open to external scrutiny, and the independent custody visitors (ICVs) have good access to the suites and generally conduct weekly visits. Custody staff respond quickly to any issues raised, and a record of each visit is held on an electronic recording system and forwarded to the scheme manager and the chief inspector for follow-up action. The scheme manager and the chairs of the ICV panels also attend custody meetings, which add to the scrutiny they provide.

Strategic partnerships to divert people from custody

There is a clear long-term aim to divert children and vulnerable people away from custody. This is understood by all the officers and staff we spoke to.

The force works well with its mental health partners at a strategic level to provide services that support diversion from custody. The mental health triage scheme is providing positive results for those with mental ill health who encounter the police.

There is also some good partnership working to keep children out of custody. However, children charged and refused bail remain in custody because local authorities can’t provide alternative accommodation.

The force works with other organisations and services to divert people from custody and minimise re-offending. Liaison and diversion services are available in both suites, and they can refer women, children, veterans and sex offenders to other organisations for support when they leave custody. However, for people at risk of re-offending, there is little in the way of wider schemes for them to be referred to.

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 have a good understanding of what makes a person vulnerable. They identified factors such as mental ill health, physical disability and age. All children are regarded as vulnerable. Officers told us they had received some training on vulnerability, although mainly through e-learning. Information to help increase their understanding is also available on the force’s intranet and in newsletters.

Officers are also aware of the importance of assessing vulnerability case by case, to take account of individual circumstances; for example, a person’s living conditions can be a good indicator of whether a person may need help. Officers said they try to find out as much information as possible about the person and any vulnerability they may have, to help establish what action to take when dealing with an incident, and whether to make an arrest.

Frontline officers reported that the information given to them by the force call handlers (who take calls from the public) to help them respond to incidents varies in quality. They said information given isn’t always detailed enough and, if the call centre is busy when they ask for more information, it isn’t always given. They can get additional information and police intelligence through their laptops, but it isn’t always possible to use these when responding to an incident, particularly as there is often only one officer attending. This means officers don’t always have all the information on any individuals involved in an incident readily available. Therefore, when making decisions on what to do, they primarily rely on what they see happening at an incident, as well as any information they can glean from those involved.

Children are only taken into custody as a last resort. Frontline officers avoid arresting children by using alternative approaches, such as taking the child to another family member if a situation needs calming down, arranging voluntary attendance interviews, using community resolutions, or speaking or referring to the Youth Offending Service to see if it can offer any other solutions or interventions.

Before arresting a child, frontline officers speak to their supervisor to discuss the circumstances of arrest and contact the custody officer to say why they are bringing a child into custody. Sometimes the seriousness of the offence and the risk of further offending makes it necessary to arrest a child and take them into custody. In most of the custody records we assessed, it was clear why it had been necessary to do this.

Frontline officers feel well supported when dealing with incidents involving people with mental ill health. The mental health street triage scheme has two cars staffed with a police officer and a mental health professional, operating between 2.00pm and 2.00am. The staff give advice and assistance to officers. If needed, and when possible, they attend incidents and deal with the person directly. Frontline officers told us that this support results in them detaining fewer people under section 136 of the Mental Health Act 1983, because other solutions are found. This makes better use of police officer time and is a better outcome for the individual in mental health crisis.

When it is necessary to detain a person under section 136, officers take them to a health-based place of safety (a designated mental health hospital or mental health ward within a general hospital or A&E). This usually involves waiting with the person until a mental health assessment can take place, which can take a long time. Officers said waits could last for the duration of a whole shift. Sometimes, if a place of safety isn’t available or the detainee has other medical needs, individuals are taken to A&E departments, but again this involves long waits.

People detained under section 136 should be transported to a health-based place of safety by ambulance. Officers said that if the wait for an ambulance was too long, they contacted the place of safety to ask if they could bring the person by car. This is to minimise waiting times in the police car or at the scene of the incident and is likely to be agreed to if there is space at the place of safety to accept the person.

Frontline officers should only take people detained under section 136 to custody in exceptional circumstances. Those we spoke to could not recall any recent cases when this had occurred.

When an individual has committed an offence that requires arrest, officers take them to custody. If any mental health needs are, or become, evident, these are dealt with in custody. Officers said they continue with any enquiries while the detainee waits for assessment by mental health professionals. The enquiries stop if a mental health assessment results in detention under mental health legislation.

Frontline officers told us they thought that mental health assessments in custody were carried out without too much delay. However, on some occasions, assessments don’t always happen within the 24-hour time limit for keeping a person in custody. If concerns remain about a detainee after this time has elapsed, they are further detained under section 136 and taken to hospital for assessment.

Police officers decide whether to transport detainees to custody in a police car or van based on the risk involved. For example, for detainees under the influence of alcohol or drugs they are likely to use a police van or call an ambulance. There are no specific arrangements for wheelchair users or people with mobility issues. In these circumstances, officers consider whether a voluntary attendance interview may be more appropriate. They gave a couple of examples where this had occurred. In the case of a wheelchair user who is arrested regularly, officers said they work with the person to help them in and out of the car and take the wheelchair to the custody suite with them.

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 courteously and respectfully with detainees. They take the time to explain processes and put detainees at ease.

The booking-in areas are quite small and become cramped when the suites are busy. Custody officers are mindful of this and try to avoid overcrowding but aren’t always successful. The booking-in areas are also noisy, which limits effective communication. Booking-in desks are of a suitable height but afford insufficient privacy, particularly when other detainees are also in the area. Detainees are routinely offered the opportunity to speak in private with a member of staff, but this is after sensitive matters have been discussed.

Shower areas are sufficiently private to maintain a detainee’s dignity when they use them. Each custody suite has visible signs saying CCTV is operating. However, in the few cells that have CCTV there are no signs and detainees located in them are not routinely advised of this coverage, or that the toilet area is obscured from view.

Strip searches take place in a designated private room, preventing detainees from being seen by others and maintaining their dignity. However, the lack of CCTV coverage does not allow searches to be recorded, even if there is a reason to do so.

Some practices are innately disrespectful and don’t adequately protect the dignity of detainees. Although they are not issued by all custody officers, the use of green boiler suits for detainees to wear is demeaning. Neither these nor anti-rip suits are adequate replacement clothing, particularly for interview (PACE Code C paragraph 8.5). The routine removal of footwear and failure to provide replacements leads to many detainees walking around custody in their socks. (See areas for improvement under ‘Detainee care’.)

Meeting diverse and individual needs

Although custody staff do their best to meet diverse needs, there are some barriers to consistently achieving this, including lack of training for custody staff on the needs of detainees with protected characteristics or from minority groups. Despite this, most staff adopt a mature and sensible approach and do what they can to meet these needs.

Neither of the custody suites cater adequately for detainees with disabilities or impaired mobility. There are no adapted cells, toilets or shower facilities. Some benches are very low to the ground. There is only one extra thick mattress in each suite that can be used to raise the height, and this isn’t always sufficient. This results in some detainees making their own adaptations, which is unsatisfactory. For example, a detainee with a back problem, who couldn’t bend down to sit on the low bench, made a makeshift seat on the toilet from a folded-up mattress, pillow and blanket.

The two wheelchairs at Nuneaton are poorly maintained and not fit for purpose, and there is no wheelchair at Leamington. It is positive that, subject to risk assessment, officers allow detainees to keep mobility aids in their cells.

There are no coloured bands on cell walls to assist those with impaired sight, or hearing loops in suites to assist those with impaired hearing. There is, however, a copy of PACE Code C in Braille format in each suite, although nothing in easy read format.

Women are not explicitly told that they can have access to a female member of staff, or that they can speak with them in private, as set out in APP guidance. They are generally asked during booking in if they have any menstrual care needs. Each suite stocks a reasonable range of feminine hygiene products, but disposal arrangements rely on custody staff taking used products away. This is unsatisfactory.

The provision for detainees who speak little or no English is reasonable. There is good use of the telephone interpreting service during booking in, but it is not used as often for other important processes, such as reviews of detention, biometrics, general care and welfare checks and release. This potentially limits detainee understanding of these processes. Telephones are used on loudspeaker, which reduces privacy for detainees.

Custody officers can access rights and entitlements in a range of languages, and most are aware of other translated documents that they can access and issue if necessary.

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

On arrival, detainees are routinely asked about religious needs and can observe their faith while in custody. Both suites have a private room for worship – a facility which we don’t normally see in custody suites. Each suite has a supply of religious items and texts, but these are not stored respectfully, and some main faiths are not adequately provided for.

Each suite has a useful information booklet about how to assist people who have difficulty with communicating, and most staff have some awareness of neurodiverse conditions. We saw some good care given to detainees with neurodivergent conditions such as ADHD and autism, recognising their individual needs. This included giving them space, good use of the outside exercise area, and avoiding placing them in a cell if possible, or using glass-fronted cells where this was unavoidable. A football is available at each suite, which some staff see as a valuable distraction tool, but other custody staff advise that the balls aren’t usually given out to detainees.

Risk assessments

The approach to identifying risk is generally good, but there are significant weaknesses in its management. Some working practices mean that the force isn’t ensuring the safety of detainees. This is a cause of concern that we expect the force to address immediately.

While some detainees are booked into custody promptly, others can wait a long time in holding rooms or vehicles before their detention is authorised (see below, Individual legal rights). When queues form there is little management to triage risks or to prioritise children or vulnerable detainees for booking in.

While 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 template and ask relevant supplementary and probing questions when required. There is routine cross-referencing with the police national computer warning markers to help identify additional risk factors. However, arresting and escorting officers are rarely asked if they have any relevant information to inform the risk assessments. There are also sometimes delays in completing risk assessments, particularly if detainees are under the influence of drugs and/or alcohol or are unco-operative on arrival.

Observations of detainees are generally set at a level that is commensurate with the risks presented. However, it is of concern that the detainees who are under the influence of alcohol and/or drugs and who are on Level 2 rousal checks (per APP guidance) are often taken off checks too quickly, with poor justification for making this decision recorded. Detention officers rouse detainees in the right way and record this adequately, but there is little consistency of staff completing the rousal checks. This makes it difficult to readily identify changes in a detainee’s behaviour or condition – something that is particularly important for those under the influence of alcohol or drugs.

Checks that don’t involve rousing the detainee are often carried out solely by looking through the cell spyhole, which doesn’t constitute an acceptable welfare check. The frequency of checks conducted on detainees is mostly as required, but we found some late visits, often with poor justification recorded, for example: “delayed as busy block”. Some custody records show multiple cell checks recorded rather than individualised to the detainee, which is poor. As with the rousal checks, different staff members carry out the checks, which limits the ability of officers to easily recognise any changes in the detainees’ condition. These practices don’t follow APP guidance.

When detainees are assessed as needing closer observation, at either Level 3 (constant observation via CCTV) or Level 4 (physical supervision in close proximity) the officer(s) responsible for the observations should be fully briefed by the custody officer. However, the quality of briefings is inconsistent, and some officers only ever receive a handover briefing from the officers they take over from.

Officers conducting these duties frequently remain in post for long periods without any breaks, and some officers are not always properly focused on their duties. For example, we observed some using their mobile telephones when they should be vigilant in supervising detainees. Custody staff should conduct welfare checks on detainees who are subject to Level 4 supervision, but this isn’t always happening. These practices also don’t follow APP guidance.

The content of handovers is generally good and has a sufficient focus on risk and welfare. However, not all custody staff, including healthcare professionals, are routinely involved. Custody officers take their handover at the booking-in desk, while detention officers hold a separate handover in the back office, and there is no routine sharing of information afterwards. After receiving the handover, custody officers don’t consistently visit detainees in their care. When they do, they don’t always speak or otherwise engage with detainees. Again, these practices don’t follow APP guidance.

Custody officers routinely remove footwear and clothing with cords from detainees rather than deciding this on an individual risk assessment. There is rarely any record of the justification for this. As in our last inspection, anti-rip clothing continues to be used frequently, often without an adequate rationale recorded. Sometimes the reason is that the detainee hasn’t answered the risk assessment questions – this is contrary to force policy. On occasion the use of anti-rip clothing appears pre-emptive, or to mitigate risks which could potentially be managed through higher levels of observation. Even when detainees are on a higher level of observation, their clothing is often still replaced, which is a poor outcome for the detainee. These practices are a disproportionate approach to managing individual risks.

Cell call bells are audible and generally responded to promptly via an intercom system. However, not all custody staff carry anti-ligature knives, and non-custody staff rarely have access to anti-ligature knives. This limits the ability to respond if needed on entering a cell, compromising detainee safety, and it is poor practice.

Metal detector arches are available in both custody suites, but not all detainees are searched using this equipment.

The management and control of cell keys is poor. They are often handed to non‑custody staff, which diminishes the control that custody staff should maintain over detainees and others in the suite.

Individual legal rights

The force cannot show how long detainees wait to be booked into custody after their arrival. However, we observed, were told by frontline officers, and found in custody records, that some detainees wait a long time – on occasion, more than two hours. There is often only one custody officer on duty, so when there is more than one detainee to be booked in, or if there are other pending tasks such as solicitors/interpreters/appropriate adults (AAs) to deal with, there are delays. This isn’t a good outcome for the detainees.

Custody officers appropriately authorise detention. Arresting officers provide detailed circumstances of arrest and explain why detention is necessary (PACE Code G), allowing informed decisions to be made. Custody officers confidently refuse to detain people if their circumstances don’t meet the necessity and proportionality criteria (PACE Code G).

The force diverts people away from custody where appropriate. Voluntary attendance interviews are encouraged to help progress investigations without unnecessary arrest and detention, and the force has a mobile interviewing unit to help carry these out. However, it doesn’t record how many voluntary attendance interviews are undertaken, so can’t assess how effectively it deals with cases in this way. The force also uses restorative justice (the collective resolution between victim and offender as to how to deal with the consequences of an offence) as an alternative to custody.

Detainees should be kept in custody for the minimum time possible, but some cases are not progressed quickly enough. This results in detainees spending long periods in custody, and potentially longer than necessary. Custody officers don’t always have the time to check and chase up investigations to ensure they are happening as quickly as possible. In one case a detainee who attended custody in the morning for breach of bail conditions had to be released later that day because she could not be presented to court within the required 24 hours. The force has records of how long detainees spend in custody before release pre-charge, but not overall detention times, which would give a more accurate picture of the outcomes achieved for the detainees.

During our custody visits we didn’t see any immigration detainees. Information provided by the force shows numbers are decreasing year on year. In the year up to 31 August 2021, immigration detainees spent an average of seven hours and 32 minutes in custody after the immigration papers (IS91) were served, which isn’t excessive.

Custody officers gave good explanations to detainees about their three main rights and entitlements. These are: to have someone informed of their arrest, to consult a solicitor and access free independent legal advice, and to consult the PACE codes of practice. Detainees were given or offered an information leaflet setting out these rights, Remember your rights whilst detained. However, they were not always offered the PACE Code C booklet, and the booklets at Nuneaton were not the latest version (August 2019). During our inspection, the force ordered these.

We had concerns in some cases that detainees were not receiving their rights and entitlements as they should:

• Where detainees were taken straight to their cells due to being too unfit to be given these rights (usually because they were under the influence of alcohol or drugs) it isn’t clear that they were subsequently given their rights and entitlements at the earliest opportunity. In one case the provision of rights and entitlements wasn’t recorded until after the detainee had been interviewed, and in another not until after the detainee had been charged.
• In three cases detainees were held incommunicado, which meant that their right to have someone informed of their arrest was delayed. Although the incommunicado was appropriately authorised, there was no record of it being lifted or of the nominated person (the person who the detainee asks to be contacted) being notified. Records indicated the detainees were interviewed and released on bail without ever receiving this right.
• In one of the cases above the detainee had initially asked for the duty solicitor but later changed her mind and wanted to be interviewed. This was authorised by a sergeant and the interview was conducted. There was no record of the solicitor having been informed or spoken to. This doesn’t meet the requirements of paragraph 6.6 D of PACE Code C, as this should have been authorised by an inspector.

Posters advising detainees of their right to free legal advice in different languages, which have lists of languages printed on both sides of the paper, only had one side displayed, so only half of the available languages could be seen.

Not all the custody officers we spoke to were aware of the requirements of Annex M. But they were able to access translated documents and records for non-English speaking detainees and those who have difficulty understanding English. However, there are no copies of the easy read format of the rights and entitlements leaflets at either custody suite. These should be given to children, but we also saw some other detainees who would have benefitted from them.

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

Custody officers were aware of how to contact the relevant embassies, consulates or high commissions for foreign nationals coming into custody if detainees requested this. We observed two cases where officers did this proactively.

DNA is stored in locked freezers and is regularly collected from the suites.

Reviews of detention

Reviews of detention are not always carried out well or in the best interests of the detainee. The overall approach is a cause of concern because the force isn’t following PACE Code C and in some cases is in breach of section 40 of PACE.

Most reviews of detention are carried out on time, but some are early. The reason for any early reviews isn’t always reflected on the custody record but in the cases we looked at it often seemed to be for the convenience of the reviewing inspector rather than in the detainee’s interest.

Most reviews are carried out by telephone, including for children and vulnerable adults, which is poor practice, and does not meet the requirements of PACE Code C paragraph 15.3 C. The custody record doesn’t always say why a review has been conducted by telephone, which it should do to meet the requirements of PACE Code C paragraph 15.14. A few reviews were incorrectly recorded as having been done in person when in fact the inspector didn’t see the detainee.

In the reviews we observed detainees were treated courteously. They were reminded of their rights and entitlements, and their welfare was discussed. However, there were some occasions where detainees were either not informed that their continued detention was authorised, or their detention was authorised before the detainees were given the opportunity to make any representations (PACE Code C paragraph 15.3).

There are numerous cases where reviews took place while detainees were asleep, but detainees were rarely informed of this, nor were they asked if they wanted to make any representations as soon as it was practicable to do so (PACE Code C paragraph 15.7). Often the detainee was only reminded when they were due to be released, or at least, this is what the custody record showed. In four cases reviews of detention were not carried out at all, which is a breach of section 40 of 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 needs to be better. Despite the force having governance processes to monitor suspects who are bailed or released under investigation, many cases are taking too long.

Our custody record analysis showed 47 percent of cases were finalised during the first period of detention. This means that many detainees are bailed or released under investigation pending further enquiries. They then wait too long for their cases to be completed.

Frontline supervisors are responsible for the management of investigations of suspects. There is no compliance or auditing process to ascertain how well cases are progressing. Information given by the force showed that over a third of cases where the detainee was released under investigation are older than 12 months.

Notices are given to detainees when they are released under investigation outlining the offences they may be committing if they interfere with victims or witnesses while the investigation is in progress. However, this isn’t always explained to them orally.

Complaints

Detainees wishing to make a complaint while in custody aren’t always able to do so before they are released.

The custody staff we spoke to are clear on the procedure for taking a complaint from a detainee. Custody officers told us that if a complaint is made about service dissatisfaction, then they pass the details to the force’s professional standards department. If the complaint involves a criminal allegation, they inform the duty inspector who then deals with it. However, our case audits and observations showed the procedure isn’t always followed, with complaints not always taken as they should be.

Information supplied by the force shows only six complaints recorded in the six months preceding our inspection. However, we found complaints that had not been recorded, suggesting that not all complaints are being gathered.

At both custody suites the leaflets explaining how to complain are out of date and refer to the Independent Police Complaints Commission rather than the current IOPC. The notices displayed that inform detainees of the procedure if they wish to make a complaint are also out of date. However, the leaflet Remember your rights whilst detained, which is offered to detainees when they are booked into custody, contains more accurate information about complaints.

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 Warwickshire are comprised of two full-time designated suites at Nuneaton and Leamington.

General conditions and cleanliness throughout the facilities are good. There is some natural light in all cells, and no evident graffiti. The suites are well maintained and benefit from a robust internal inspection programme, which provides early identification of any additional maintenance works that are required.

There are potential ligature points in both facilities, mainly due to the design of toilets, air vents and some loose hatches. A comprehensive illustrative report detailing these and the general condition of the suites was provided during the inspection.

Most of the cells have benches that are slightly lower in height than the expected standard. All cells have sinks and toilets; the latter are appropriately obscured from view on CCTV monitors.

Daily and weekly safety maintenance checks of the physical environment, including the cells and communal areas, are completed as required by APP guidance. Repairs are mostly completed quickly, but the faults log isn’t always updated to record when problems are resolved.

The CCTV system is old and there is poor coverage in both suites and in cells. Plans to install a new system are well advanced.

Most custody staff are fully aware of emergency evacuation procedures, including how and where to evacuate detainees in an emergency. However, few of them have experienced a physical evacuation to ensure the procedures work in practice. Force data shows there has been an evacuation drill at both custody suites in the past six months, but does not identify which custody staff were present or record any custody-related learning points. There are sufficient sets of handcuffs in the custody suites to evacuate the detainees safely if required.

Safety: use of force

Information on the use of force in custody isn’t accurate, and little or no information is recorded on custody records about any force used. This makes it difficult to know how often force is used in custody and what type of force is used. Officers and staff using force on a detainee are required to submit a use of force form, but this isn’t always happening. In seven out of nine cases reviewed, officers had not submitted the required form.

There is limited CCTV coverage in the custody suites, so if force is used on a detainee, depending on where the incident occurs, footage may not be recorded. This means it can’t subsequently be reviewed to assess whether the force used was justified and how well the incident was handled. Our review of cases as part of the inspection was restricted because of the limited CCTV. We were only able to review nine cases.

However, most of these nine cases were well handled. We saw officers de-escalating situations and avoiding or minimising use of force by being patient with detainees and offering reassurance. When force was used, it was generally proportionate and justified. We found a good way of working in one case, which we highlighted to the force for them to circulate further. In three cases reviewed, the tactics were inappropriate and not approved techniques. We referred these cases back to the force for it to review and learn from.

We had concerns over a use-of-force incident that occurred immediately prior to our inspection. Warwickshire police had already identified these concerns and we were told that their professional standards department are investigating.

Where force is used to remove clothing, it is our view that this could be avoided through increased levels of observation rather than forcibly removing clothing (see above, Risk assessments). However, in the cases we looked at where officers used force to remove clothing, there was generally good attention to maintaining the detainees’ dignity.

There is little quality assurance of use-of-force incidents in custody. A custody officer reviews just two custody records each month, which isn’t enough. Unless incidents have been properly recorded on the custody record there is no easy way of identifying them for review. This makes it difficult for Warwickshire Police to show that the use of force is always justified and proportionate.

We observed that some compliant detainees had handcuffs removed quickly on arrival in custody, but others remained in handcuffs for too long – up to almost two hours in one case we reviewed. The time that handcuffs are removed isn’t recorded on the custody record, which would show whether detainees are held in handcuffs for longer than necessary.

From the custody records we reviewed, and from what we could see on CCTV, strip searches are properly authorised and justified.

Most custody officers and detention officers are up to date with their personal safety training. Refresher courses are booked for those whose training is out of date.

Detainee care

Overall, the approach to looking after detainees is reasonably good. Detainees spoke positively about the care they received during their stay in custody.

Custody staff generally show a caring attitude to the detainees they are responsible for. However, the recording of aspects of detainee care on custody logs lacks detail. There were few entries to show that care provisions had been offered to detainees. We observed that in practice, and particularly around offers of food and drinks and access to time in the fresh air, the level of care offered is much better than that recorded.

Food preparation areas are generally clean and tidy, but the microwaves used to heat meals are often dirty. Cutlery isn’t always properly sanitised between uses. The guidance for officers to refer to on allergies and other dietary requirements isn’t up to date. It was suggested during a discussion with a detention officer that a tuna pasta bake is suitable for vegan and vegetarian diets. There is, however, a wide range of microwaveable meals suitable for most dietary requirements, and these are offered frequently. Cereal bars are popular. A good range of drinks including squash and hot chocolate are available and offered to detainees regularly.

For detainees who remain in custody for longer periods or for whom custody food is unsuitable, consideration is given to purchasing food or allowing sealed food to be brought in for them, which is good. Water from the taps in the cells is drinkable, but there are no signs in cells at Nuneaton to advise detainees of this.

Use of the outside exercise yards to give detainees time in the fresh air is better than we often see. Both yards are clean, offer some shelter during inclement weather and are frequently used.

The provision of other types of detainee care is often more limited. Despite each custody suite having a range of books and magazines they are rarely given out without being asked for. Reading materials are generally only available in English, and there is little suitable for children. A soft football is available in each suite, but they are offered infrequently. There are otherwise too few distraction activities readily available, although custody officers will consider the provision of paper and a pencil if requested.

It is positive that detainees who are held in custody overnight and who are required to attend court are routinely offered the opportunity to shower or wash. Showers in each suite offer sufficient privacy. During our visit the water pressure in Leamington Spa was very low and showers gave just a trickle of water, but the offer to wash was still appreciated by detainees. We saw detainees being given the opportunity to wash and clean their teeth at other times during the day, but these occasions are sometimes limited if staff aren’t available to supervise, and particularly if the staff member needs to be of the same gender as the detainee.

Toilet paper is still not provided routinely. Rolls are generally stored on a cell door handle, which is unhygienic, and only a small amount of paper is given on request, which is unsatisfactory.

There is generally sufficient replacement clothing and footwear available. All footwear and clothing with cords is removed routinely. The rationale for replacing clothing with green boilersuits rather than jogging bottoms and tops is unclear, and we don’t consider the boilersuits to be adequate replacement clothing. It is also poor that, on having their footwear removed, detainees aren’t routinely provided with replacements.

All cells are equipped with a pillow and thin mattress, although some are damaged. Only one thicker mattress is available in each suite. Sufficient clean blankets are available and are generally provided routinely. Additional blankets are readily provided on request if detainees are cold.

There is a visiting room in each suite. This is positive, and custody officers 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 with (both frontline and custody-based) during the inspection showed a clear understanding of their role and its importance in safeguarding vulnerable adults and children. There is a shared responsibility to ensure safeguarding risks are addressed and referrals made where needed.

Liaison and diversion (L&D) practitioners assess every child in custody, as well as other specific vulnerable groups (including women and veterans) or when requested to by the custody officer. They also make referrals to other organisations to support individuals during their time in custody and when they leave.

However, safeguarding considerations and any actions taken towards the safe care and release of children or vulnerable adults are often not well recorded on custody records. The L&D team can’t directly access Athena, the force custody system, so it isn’t always clear if they have been involved.

Custody officers recognise the importance of securing appropriate adults (AAs) as early on in a child’s or vulnerable adult’s detention as possible, but the arrangements are often left to others. Arresting officers may arrange AAs before a person is taken into custody, so that the detainee can have prompt support. If this isn’t possible, investigating officers usually arrange an AA once the detainee is in custody.

Friends, family or carers are sought to act as AAs in the first instance. If this isn’t possible (either because they can’t attend or because they were involved in the incident), other arrangements are made. During daytime hours (9.00am to 5.00pm), AAs for children are provided by Youth Justice Service (YJS) teams. These are located in the Justice Centre where the custody suites are also based. Outside these hours, AAs for children are requested from social services’ emergency duty teams (EDT). AAs for vulnerable adults are requested through a contracted service with the Appropriate Adult Service (TAAS), who operate on a 24-hour basis.

We were told by custody officers that waiting times for AAs are generally good. Children often receive early support as an AA from the YJS is usually able to arrive quickly, and attend while the child receives their rights and entitlements during their initial assessment and booking into custody. EDT support during evening and night hours isn’t as prompt, as it depends on the staff available. But they will still attend, and support children so that interviews can go ahead, and cases can progress.

The service from TAAS is generally aimed at vulnerable adults, but their AAs can also attend for children. Custody officers said TAAS provide a generally good service, although AA attendance is most likely to be for when the person is ready to be interviewed. The Office of the Police and Crime Commissioner is currently setting up a volunteer scheme to offer additional support for vulnerable adults.

While the arrangements to support vulnerable adults are generally satisfactory, we aren’t assured that all vulnerable adults receive an AA when they should. We found some cases where a detainee’s presentation and history indicated they may have required an AA, but no consideration was given to this.

The force does not monitor AA provision to see if it meets the needs of detainees. The custody records we examined sometimes had confusing information about when AAs were requested, when they arrived and/or whether the person attending was a family member or carer or from an agency or scheme. This makes it difficult to assess how long detainees wait before an AA arrives to support them, and to know which custody processes they are present for. The force has started to increase its scrutiny on this, but more work needs to be done.

The force provides guidance to AAs to help them better understand their role. We observed custody officers giving out the guidance and explaining the role orally. This is an improvement since our last inspection.

Most custody officers only detain children in custody where necessary. Discussions between custody and arresting or investigating officers usually occur before a child is taken into custody, to see if alternatives are appropriate and available (see above, Section 2. Pre-custody: first point of contact). We observed two cases where detention of children was refused in favour of other routes. In one case arresting officers were told to take a child who had never been arrested before and was arrested on suspicion of criminal damage to a family member and deal with the matter by voluntary interview.

Custody officers told us they tried to reduce the length of time each child spends in custody where possible, using either bail or releasing under investigation, if appropriate. However, our case reviews found several children detained for long periods, and it wasn’t always evident what steps, if any, were taken to try to progress matters more quickly. Information provided by the force showed the average length of detention for children (pre-charge only) detained between 1 September 2020–31 August 2021 was 11 hours 57 minutes. There is very little difference when compared with adult pre-charge detention times during the same period (11 hours 58 minutes).

When a child is detained contact is usually quickly made to notify and share information with the YJS or social services. Although there are no designated cells or detention rooms for children at either custody suite, custody officers told us they tried to keep a child out of a cell where it is possible to do so, for example, by having them sit with a detention officer or AA in an interview room.

However, few other specific care and welfare provisions are available to help children during their time in custody. There are no child-friendly reading materials or easy read rights and entitlement booklets to help them better understand their situation. Foam footballs are available to help distract children and vulnerable adults, and we saw some instances of these being offered, although not specifically to children.

The force understands its legal responsibility under the Children and Young Person’s Act 1933 to provide a named female officer or staff member to oversee the welfare of, and be available to speak with, any girls in custody. However, it isn’t clear how this happens in practice, if at all. In two custody records we looked at, one provided no indication as to who the named officer was, nor whether the detainee had been informed of any provision or spoken to by the officer. In the other, it was recorded that this provision wasn’t necessary. We told the force of our concerns and they quickly reminded custody officers of their responsibilities towards girls held in custody.

There is good governance and oversight of children in custody. The chief inspector for custody reviews any case where a child is held in custody to assess how they have been dealt with and determine concerns or learning points. Children detained in custody are discussed at the force’s daily management meeting, which is attended by senior officers. They are also discussed at the regular custody meetings, and there is a specific custody officer responsible for safeguarding to offer further scrutiny.

A monthly partnership forum has recently been set up with organisations with which the force works, including social services and the youth justice service (YJS), to evaluate children in custody and the effectiveness of the joint arrangements to support them.

However, this scrutiny of children isn’t resulting in improvements for children who are charged and refused bail. Local authorities have a statutory responsibility to move these children to alternative accommodation while they wait for their court appearance. Although relatively few children are charged and refused bail in Warwickshire, they aren’t moved.

In the year to 31 August 2021, 16 children were charged and refused bail. Custody officers requested that the local authority provide secure accommodation in six of these cases, and appropriate (non-secure) accommodation in the remainder. No accommodation was provided in any of the cases. There is no secure accommodation within a reasonable travel time. This is a poor outcome for those children.

In the custody records we looked at it wasn’t clear what, if any, efforts had been made to find other accommodation after the requests had been made. Nor were there details of any escalation to senior officers. The juvenile detention certificates, which are completed for any child remaining in custody post-charge, didn’t always provide a clear explanation as to why the child had not been moved, nor details of any efforts made to this end.

We were told that local authorities are considering plans to increase the number of non-secure beds. This may improve the situation for some detained children in future.

Governance of health care

Mitie Care and Custody provide physical healthcare and Coventry and Warwickshire Partnership NHS Trust provide substance misuse and mental health support in both custody suites. There is good collaboration and close working between health providers and the force. Effective monthly contract monitoring is in place.

Clinical governance arrangements are effective, with regular meetings informing clinical practice. The web-based service user management system, used by custody staff to refer patients to the health care professionals (HCPs), produces accurate performance data which is analysed and reported to Mitie senior managers and the force.

Healthcare HCP response times are graded according to clinical and forensic need. Performance data provided by the provider for the past six months indicates response times of 90 minutes in over 96% of referrals. In our own custody records analysis, the mean time for HCP attendance from referral was 68 minutes.

Policies are in place to report and manage incidents, and a confidential complaints system is advertised in both suites. Staff appraisals are taking place. However, there are insufficient arrangements in place for the clinical and managerial supervision of HCPs.

HCPs aren’t assigned to a single custody suite, and are required to drive between the two, often multiple times per shift. This journey takes more than 40 minutes each way. While there is no evidence of this affecting patient care negatively, there are significant delays in completing important safety checks on medical equipment and medicines, caused by a lack of time. HCPs told us that, due to the pressures of having to attend suites within agreed timescales, clinical notes aren’t being completed with the immediacy required to make sure the detainees’ records are always up to date. They also said their own wellbeing is being affected negatively.

Clinical rooms in both suites generally meet infection prevention standards, and providers have plentiful and uninterrupted access to personal protective equipment (PPE).

All patient assessments and interactions in clinical rooms are undertaken with the door open and custody staff generally standing at the door. This practice is inappropriate and breaches patient confidentiality. In Nuneaton, the clinical room door opens to the booking-in area, which is often noisy. Despite being a fire door, it is wedged open. The force told us they were working with Mitie to address this concern.

Each clinical room has a standard emergency bag containing the necessary life‑saving equipment. Their contents are appropriate and in line with national standards, and each emergency bag contains a defibrillator. All custody staff we spoke to have received basic life-support training. However, detention officers only receive refresher training every three years, which is too long.

Patient care

Mitie Care and Custody have a thorough and detailed clinical competency framework that each HCP and senior HCP is required to complete, which is good. The HCPs we met displayed excellent knowledge and are experienced in their role. All custody staff we spoke to value the support provided by the healthcare workers.

The clinical records we examined were of good quality and accurate, and all HCPs have access to the police system to record the main risks and interventions. Patient consent is obtained before each contact, and interactions we observed were professional and respectful. All detainees we spoke to were positive about healthcare services in custody.

Medicines management is generally safe and appropriate for patient care. Detainees can receive prescription medicines, which include community-prescribed opiate substitution treatment. Well-established, evidence-based protocols are used to provide symptomatic relief for detainees who are experiencing withdrawals. Custody staff can administer nicotine replacement products, which is positive.

A range of patient group directions (authorising HCPs to prescribe and administer prescription-only medicines) are signed and up to date. There is an appropriate range of stock medicines held securely in each suite. However, checks on stock balances, including controlled drugs, aren’t completed in line with best practice which creates unnecessary risk.

Substance misuse

The L&D team support and signpost detainees with drug and alcohol problems to community-based services. While no substance misuse practitioners have been based in the custody suites since the start of the COVID-19 pandemic, L&D staff have strong links with community services to disseminate information.

The L&D community engagement team help detainees to attend appointments and access the required support after their release. On leaving custody, detainees are given information including details of community-based substance misuse services. There is, however, no immediate access to sterile injecting equipment to minimise the risk of spreading blood-borne viruses.

Mental health

Any person who is regarded as vulnerable can receive support through the L&D service provided by Coventry and Warwickshire Partnership NHS Trust. There is a qualified practitioner based in each custody suite seven days a week from 7.30am to 8.00pm. The L&D team have remained in the suites throughout the pandemic.

There are good governance processes and management support for the service. The L&D service is part of the trust’s urgent care pathway, which means detainees can access mental health support swiftly and seamlessly, and L&D staff have quick and easy access to community mental health records. Detainees may also be diverted or signposted to the trust’s psychiatric clinical decisions unit. This is a voluntary service that provides a safe space for those in a mental health crisis to seek support from clinical staff.

The L&D staff have a wide range of skills and disciplines, reflecting the support on offer. They are positive about the supervision and training opportunities they receive.

There is effective contract monitoring with the force to review performance, and regular partnership meetings enhance positive working relationships. The team’s work is highly valued by custody staff and police colleagues, who told us that L&D services are the best thing to happen to the police force. The trust offers mental health training to police colleagues and invites them to join relevant training within the trust.

Detainees receive a high-quality service while in custody. Women, children, veterans and sexual offenders are offered additional support through referrals to established schemes. The L&D team communicate well with custody staff to review referrals and prioritise risk. However, this isn’t documented on the police custody record, as only one member of the L&D team has access to the custody system. This is poor, and the lack of recorded information sharing creates unnecessary risk to the detainees and the force.

If time allows, L&D staff proactively review detainees in custody to ensure their support is offered to everyone, regardless of whether a referral has been received.

Community engagement workers, overseen by the qualified staff based in custody, provide practical support for detainees after their release, with no time limit on detainees accessing this. They accompany detainees to appointments such as those made housing services and encourage them to work with other appropriate services. The L&D team have a comprehensive, up-to-date log of services throughout the county where detainees can access support.

Detainees are no longer brought into custody as a place of safety, and we were told there are no significant delays to carrying out Mental Health Act assessments in custody. However, some detainees in custody don’t have their Mental Health Act assessment before the 24-hour detention period runs out, and are subsequently further detained under section 136 of the Mental Health Act 1983, so that they can be taken to a place of safety. There is no accurate data to show how often this happens.

A street triage scheme jointly run by dedicated police officers and mental health practitioners is in operation seven days a week from 2.00pm until 2.00am. It is regarded as a significant tool in diverting vulnerable people away from custody. The trust’s data suggests that over the past six months the street triage service has received 738 referrals. Of these, 111 face-to-face interventions took place, and only 19 cases resulted in a person being detained under the Mental Health Act 1983. The remaining cases received telephone advice and support (especially when the team could not operate in the community during the pandemic).

When detainees are detained under section 136 of the Act, there can be long waits before a health-based place of safety can take them. This is due to demand for the service. It can mean police staff are asked to stay with detainees for extended periods of time.

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 ensuring detainees are released 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 generally make appropriate use of initial risk assessments and care plans to ensure that, where possible, all identified risks are addressed or mitigated before release. Particular attention is given to managing the safe release of children and vulnerable detainees. Where necessary, other relevant bodies such as the L&D team are involved to support the release. However, some custody records lack sufficient detail and don’t reflect what we saw in practice. For example, release arrangements aren’t always thoroughly recorded, and don’t always show how a detainee will get home after release.

Police officers take children and vulnerable people home if no family members or carers are available to take or transport them. Other detainees are also frequently taken home by police officers, because custody officers don’t have ready access to travel warrants or petty cash to give to them – which we expect to see, and which most other forces use. Using police transport in this way isn’t a good use of officer time. Additionally, officers aren’t always available to do this because of other operational commitments. These arrangements don’t ensure all detainees, and especially those who live a long way away, can get home safely.

Most custody officers are aware of the enhanced safeguarding arrangements for those arrested under suspicion of committing serious sexual offences. In these cases, custody officers report a good exchange of information with investigating officers and use this to assist when completing the pre-release risk assessment.

Leaflets containing information about both national and local support bodies, specific to each custody suite, are available and are given to all detainees on release, but they are only in English.

Detention officers complete electronic person escort records (ePERs) and book transport for detainees who are attending court or who have been recalled to prison. These are mostly well completed and are signed off by custody officers. Generally, custody officers supervise the transfer of detainees to the prisoner escort and custody services (PECS) staff. They complete pre-release risk assessments with detainees to ensure all identified risks have been addressed or mitigated before transfer.

Courts

Working practices ensure that once detainees are remanded they are generally presented before the first available court. This means most are held for no longer than necessary. This has improved since our previous inspection.

Detainees remanded to court are generally collected promptly in the morning. Those arrested on warrant during the day aren’t accepted directly at the local magistrates’ court and are booked into police custody. Staff report that there is some flexibility with the court, which often accepts detainees later in the afternoon. We saw a few detainees being transferred to court after 3.00pm, which prevented an unnecessary overnight stay in custody.

A video link facility is available in both custody suites to hear cases virtually if necessary. This avoids unnecessary travel to court if a detainee has a disability or is suspected of or confirmed as having COVID-19. During the inspection it was used with good effect for a wheelchair user arrested on warrant and booked into Nuneaton at 12.00pm. They then appeared promptly at court via the video link and were released from custody by 3.30pm. This shortened their time in detention and was a good outcome for the individual.

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
• Anthony Davies: HMI Constabulary and Fire & Rescue Services inspection officer
• Patricia Nixon: HMI Constabulary and Fire & Rescue Services inspection officer
• Vijay Singh: HMI Constabulary and Fire & Rescue Services inspection officer
• Ramzan Mohayuddin: HMI Constabulary and Fire & Rescue Services inspection officer
• Sutinderjit Mahil: HMI Constabulary and Fire & Rescue Services inspection officer
• Andy Reed: 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: CQC inspector
• Lynda Day: CQC inspector
• Joe Simmonds: HMI Prisons researcher
• Becky Duffield: HMI Prisons researcher

Fact page

Note: Data supplied by the force.

Force

Warwickshire

Chief constable

Debbie Tedds

Police and crime commissioner

Philip Seccombe

Geographical area

Warwickshire

Date of last police custody inspection

2014

Custody suites

• Nuneaton custody suite – 24 cells
• Leamington custody suite – 14 police cells and 7 court cells

Annual custody throughput 2020/2021

• Nuneaton – 3,983
• Leamington – 3,198

Custody staffing

• 18 custody sergeants
• 25 detention officers (Bidvest Noonan)
• 4 full-time healthcare professionals (Mitie Care and Custody)

Health service provider

Mitie Care and Custody

Back to publication

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