Report on an inspection visit to police custody suites in Wiltshire

Summary

This report describes our findings following an inspection of Wiltshire Police custody facilities. The inspection was conducted jointly by HM Inspectorate of Constabulary and Fire & Rescue Services (HMICFRS) and the Care Quality Commission (CQC) in November 2022. It is part of our programme of inspections covering every police custody suite in England and Wales.

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

To help the force improve, we have made two recommendations to it and its police and crime commissioner. These address our main causes of concern.

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

Leadership, accountability and working with partners

Wiltshire Police has clear governance structures for the safe and respectful provision of custody. But the custody matters discussed at its quarterly meetings are too limited to provide good strategic oversight. However, the force is open to external scrutiny and has made good progress in some areas since our last inspection in 2016.

The custody suites at Melksham and Swindon are clean and well maintained, although we did find some potential ligature points. We found there were usually enough staff on each shift to manage custody safely and care for detainees.

The force generally follows the Police and Criminal Evidence Act 1984 (PACE), its codes of practice and other legislation, although this doesn’t happen for all aspects of reviews of detention. The force has adopted the College of Policing’s Authorised Professional Practice (APP) but, again, this isn’t always followed.

The force monitors many areas of custody performance at a monthly management meeting. But it isn’t clear how the findings are used to identify and make any improvements needed.

The force’s governance and oversight of the use of force in custody isn’t good enough. It hasn’t improved since our last inspection and is now a cause of concern. Some information is inaccurate, incidents aren’t always properly recorded on custody records, or recorded at all, and not all staff involved in an incident complete the required use-of-force forms. This prevents any effective scrutiny over the use of force by Wiltshire Police. In our CCTV review we found use-of-force incidents weren’t always managed well.

Overall, the quality of recording on custody records isn’t good enough, and neither is the level of quality assurance.

The force understands its responsibilities under the public sector equality duty. It collects information on ethnicity, gender and age to help assess whether outcomes for detainees are fair in areas such as arrests and strip searches.

The force works well with partner organisations to divert children and vulnerable adults away from custody. Work with youth offending services tries to keep children from entering the criminal justice system. There is some good joint working with mental health services to support people with mental ill health.

Pre-custody – first point of contact

Frontline officers have a good understanding of what makes a person potentially vulnerable and take account of this when deciding what action to take. They only arrest children when no other alternatives are available. There is some good support from other organisations to help find other options.

Officers told us they feel well supported when dealing with people with mental ill health. A mental health triage service works in the force’s control room 24 hours a day, 365 days a year, providing advice and assistance to officers attending incidents. Officers told us this support helped them make informed decisions about what to do, and whether they needed to detain a person under section 136 of the Mental Health Act 1983 for their own or others’ safety.

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

Custody staff show respect to detainees and are generally patient and reassuring during their interactions with them. However, privacy for detainees in the booking-in areas is limited, especially when the suites are busy.  Detainee dignity is generally protected and detainees are suitably dressed when moving about the suite and attending interviews.

Custody staff understand how to meet the individual needs of detainees and those from protected or minority groups. The force responds well to help those with neurodiverse conditions cope with the custody environment, but provision for women could be better.

Risk identification is generally good, but there are some weaknesses with its ongoing management. Not all detainees under the influence of alcohol and/or drugs are placed on level 2 observations for rousal checks in line with APP guidance. Custody officers remove footwear and clothing with cords from detainees rather than making an individual risk assessment to decide if this is necessary. However, observation checks are on time and carried out well – including rousing detainees. Shift handovers between custody staff are very good and a considerable improvement since our last inspection.

Detainees are generally booked into custody promptly, and their detention is appropriately authorised. Arresting officers provide the circumstances of the arrest and explain the grounds for the necessity for detention well. Custody and detention officers give good explanations to detainees about their rights and entitlements and provide these appropriately.

Reviews of detention aren’t always carried out well enough, or in the best interests of detainees. Not all aspects comply with PACE and its codes of practice. Detainees are appropriately bailed or released under investigation when their investigation can’t be completed while they are in custody.

In the custody cell, safeguarding and healthcare

The custody suites are clean and well maintained. However, there are potential ligature points in both, mainly in the exercise yards and areas around the showers, and also in the cells at Swindon.

The approach to detainee care is good. Detainees spoke positively about the care they received and most were aware of what they were entitled to. Food and drinks are regularly offered and provided but some other care provisions are offered less often. This includes access to showers, exercise and reading materials.

Custody staff have good understanding of their safeguarding responsibilities for children and vulnerable adults. They arrange to deal with any concerns while in custody and on release. Children generally don’t wait too long before receiving support from an appropriate adult (AA), but this isn’t always the case for vulnerable adults.

Children are well cared for in custody. Their cases are generally dealt with quickly to keep their time in custody as short as possible. Few children are charged and remanded. But those that are, aren’t moved to alternative accommodation as they should be.

The healthcare contract has recently been awarded to Mitie Care & Custody. At the time of our inspection, it wasn’t fully implemented and there were staffing shortages. This meant there weren’t enough healthcare practitioners (HCPs) to see detainees promptly, or sometimes at all. Routine monitoring of detainees wasn’t always taking place and detainees weren’t always receiving their medicines at the required time. This is a cause of concern.

However, the force has established good monitoring arrangements to manage the contract and new staff have been recruited. The HCPs working in the suites are experienced and competent practitioners who treat detainees respectfully and carry out comprehensive assessments of their health needs.

The liaison and diversion (L&D) service provides good support to vulnerable detainees arriving in custody, helping them with areas such as housing, social problems or drug and alcohol issues. Detainees with mental health needs have these assessed promptly in custody or they are detained under section 136 of the Mental Health Act 1983 and transferred to a health-based place of safety.

Release and transfer from custody

Custody staff generally have a clear focus on making sure detainees are released safely. We saw a good level of care given to detainees on release. However, custody officers don’t always fully complete the pre-release risk assessment with the detainee present. This means that some risks identified during detention may not be considered or discussed with detainees before their release or transfer.

When detainees are remanded, they are generally transferred promptly to the next available court. This minimises their time in police custody and is an improvement since our last inspection.

Causes of concern and recommendations

Introduction

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

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

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

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

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

The expectations are grouped under five inspection areas:

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

The inspections also assess compliance with the PACE 1984, its codes of practice and the College of Policing’s Authorised Professional Practice – Detention and Custody.

The methodology for carrying out the inspections is based on:

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

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

Section 1. Leadership, accountability and working with partners

Section 1: Expected outcomes

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

Leadership

Wiltshire Police has clear governance structures for the safe and respectful provision of custody. An assistant chief constable oversees custody, supported by the superintendent head of crime standards and justice. An inspector and an experienced sergeant are responsible for the day-to-day management of custody services. The PCC also has oversight.

Custody is represented at the quarterly review of crime standards and justice meeting, chaired by the ACC. But the custody matters discussed are too limited to provide good strategic oversight. Nevertheless, the force has made good progress in some areas since our last inspection in 2016, for example, in improving support for detainees with substance misuse issues.

At an operational level, monthly management meetings chaired by the custody inspector consider more comprehensive information for custody. This includes, for example, staffing levels and complaints.

The healthcare contract has recently been awarded to Mitie Care & Custody. At the time of our inspection, this wasn’t fully implemented. We, along with the force, have concerns that health staff shortages are adversely affecting healthcare provision for detainees. This a cause of concern – see the Physical health section for more detail.

However, the force has established good monitoring arrangements to manage the contract and address these concerns in future.

There are two custody suites at Melksham and Swindon. They are clean and well maintained but we did find some potential ligature points. The force is investing in its estate and planned refurbishment works are due to start at Melksham early in 2023.

There are nine custody sergeants at each suite. Five cover general custody duties and the other four have responsibility for a specific area of custody such as mental health and children. They also cover absences in the suites when required. The force has 36 detention officers. We found there were generally enough staff on each shift to manage custody safely and care for detainees.

Initial training for both custody and detention officers follows the national programme. Training for custody officers is provided as part of an arrangement with other regional forces. There is an in-force training officer for detention officers. All custody staff attend a three-week course, followed by a shadowing period before they start their duties.

One day of continuous professional development training is provided by the force every ten weeks as part of the shift pattern. Recent topics have included awareness of neurodiversity, mental health and practical fire evacuation sessions. Staff we spoke to were positive about the training they received.

The force has adopted the College of Policing’s APP. There are no additional local policies or guidance for staff. However, APP guidance isn’t always followed particularly when managing risk, for example, setting observation levels for detainees under the influence of drugs or alcohol. Not all staff we spoke to were knowledgeable about the contents of APP guidance.

The force generally follows the Police and Criminal Evidence Act 1984 (PACE), its codes of practice and other legislation. There is good attention to ensuring the PACE Code G necessity for arrest criteria are met before detention is authorised, and detainees are given their rights and entitlements in line with PACE Code C.

But some aspects of reviews of detention don’t meet the requirements of PACE or its codes of practice. We found some cases where reviews were required but didn’t take place (a breach of section 40 of PACE) as well as telephone and sleeping reviews where requirements of Code C weren’t met.

The force records adverse incidents appropriately, although a recent move to an electronic reporting system has led to the number of reports declining. There is no specific guidance for staff on recording adverse incidents. There have been no deaths in custody since our last inspection, but two detainees committed suicide following their release. In line with guidance, these incidents were reported to the Independent Office for Police Conduct.

Accountability

The force monitors performance information at the monthly management meeting chaired by the custody inspector. This includes:

• the number of detainees held at each suite;
• the number of children coming into custody;
• waiting times for booking in;
• the number of detainees released on bail or under investigation;
• strip searches;
• use of force; and
• complaints.

However, some important areas aren’t monitored. For example, average detention times or the time detainees are held before and after charge. The force struggled to provide this data when we asked for it. In addition, we found use of force data is inaccurate.

Performance information is also considered at the quarterly performance management review meetings. But it isn’t clear how this is used to make improvements. For example, the number of children strip searched in custody has increased but the force hasn’t investigated why this might be. Similarly, little action has been taken to understand any themes in complaints.

The force’s governance and oversight of the use of force in custody isn’t good enough. It hasn’t improved since our last inspection and is now a cause of concern. Use of force is considered at the monthly management meeting. The force’s use of powers board also considers the use of force, but few cases relating to custody are reviewed. Information on the number of times force is used in custody is inaccurate. It isn’t always properly recorded on custody records and sometimes it isn’t recorded at all. Not all staff involved in an incident complete the required use-of-force forms. This means Wiltshire Police isn’t able to provide effective scrutiny of the use of force.

In our CCTV review we found use-of-force incidents weren’t always managed well. We referred four cases where we had concerns to the force. Wiltshire Police has its own quality assurance arrangements, but these don’t seem to have picked up the type of concerns we identified. Wiltshire Police can’t show that when force is used in custody it is necessary, justified and proportionate.

The quality of recording on custody records isn’t good enough. Important information is sometimes missing, such as the justification for the removal of clothing and the time handcuffs are removed. The recording of reviews of detention and welfare checks often relies on standard text entries with little or no added narrative relevant to the detainee. This is poor practice.

There are quality assurance arrangements. Custody support sergeants dip sample approximately 40 records each month from both suites and check them against a very detailed set of indicators. Despite this, the force hadn’t identified some of the concerns we found. And it isn’t clear how any quality assurance findings, especially when they show themes or trends, are used to make improvements.

The force understands its responsibilities under the public sector equality duty. Training for custody staff on equality, diversity and inclusion is part of the initial training course. Some topics, such as neurodiversity, have been included in the continuing professional development training.

The force collects information to help it assess whether outcomes for detainees are fair. It breaks down arrests, strip searches and any use-of-force incidents in custody by ethnicity, gender and age. These assessments haven’t identified any specific concerns about disproportionality.

The force is open to external scrutiny from the independent custody visitor (ICV) scheme. ICVs visit the suites regularly and can enter them at any time using their own entry cards. ICVs report good working relationships with custody staff, who respond quickly to any issues raised. Feedback from visits is reported to regular meetings with the custody inspector and any recurring concerns are discussed and dealt with.

There is also external scrutiny by the office of the PCC. The PCC attends strategic performance meetings and has access to force performance data held on its IT systems.

Working with partners

There is a clear priority to divert children and vulnerable adults away from custody. The force works well with partner organisations to achieve this.

The force and its partners have a strong commitment to work together to keep children out of custody and from entering the criminal justice system. Diversion work by the youth offending teams supports this and helps prevent offending behaviour.

The L&D service and its commissioning body, also work to help adults who are vulnerable and steer them away from the criminal justice system. Schemes include:

• The Nelson Trust which offers support to female detainees; and
• Turning Point which supports detainees with drug and alcohol dependency.

The force works effectively with mental health partners who provide a 24/7 mental health triage service in the control room to help deal with incidents involving people with mental ill health. There are dedicated officers responsible for working with partners to improve outcomes for people with mental ill health.

Section 2. Pre-custody – first point of contact

Section 2: Expected outcomes

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

Assessment and diversion at first point of contact

Frontline officers have a good understanding of what makes a person potentially vulnerable and take account of this when deciding whether to arrest or deal with the incident in another way. They consider factors such as age, mental ill health, learning difficulties and substance misuse. And they also consider whether there are any potential harm concerns which might mean an arrest is needed to protect the person involved in the offence, or any others.

Regular training is provided and this has included guest speakers from local authority social services and safeguarding teams to talk about the needs of children and vulnerable people. Officers have also received training on recognising vulnerabilities, including neurodiversity and mental health. Training is given both face-to-face and online and staff generally spoke positively about it.

Officers told us that information from call handlers (who take calls from the public) about incidents and any persons involved is generally good. The call handlers pass on information held on the force’s IT systems and officers can also access information from their mobile phones and laptops. Overall, officers felt they have enough information to make informed decisions.

Frontline officers try to divert children away from custody where possible, and only arrest when no other alternatives are available. They consider:

• arranging to interview the child later outside of custody;
• referring the child to the local neighbourhood policing team who may be able to work with them and their family;
• using community resolutions; and
• referring the child to the youth offending team who can offer support and intervention activities for lower-level offences without the need for an arrest.

Officers told us they feel well supported when dealing with people with mental ill health. Officers can telephone a mental health triage service in the control room 24 hours a day. Mental health professionals check the health records of people, provide advice and speak directly with the person if needed.

Officers value this service and said it helped them make informed decisions about what to do, and whether they should detain a person under section 136 of the Mental Health Act 1983 for their own or others’ safety. In their view, the service helps avoid some section 136 detentions because alternative health arrangements are made. For example, by making appointments for the person to see their GP or a mental health professional.

When a person is detained under section 136, the mental health professionals help officers further by liaising with health-based places of safety to arrange a Mental Health Act assessment and bed space. However, officers told us about long waits with detainees at hospitals or health-based places of safety pending the assessment. This is poor use of police time.

Custody isn’t used as a place of safety for section 136 detainees unless there are exceptional circumstances. However, when a person has committed an offence, officers arrest them unless there are clear mental health concerns. Any subsequent concerns are dealt with in custody. If the need for a Mental Health Act assessment is identified but can’t be arranged in custody, the person is detained under section 136. Frontline officers said they are then called to take the person to hospital or a health‑based place of safety.

People detained under section 136 should be transported by ambulance. Long wait times for these means that sometimes police vehicles are used instead. People who are arrested are taken to custody in police vehicles. There are no arrangements for detainees with mobility or other needs, but officers said they would use their common sense to make any arrangements.

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

Section 3: Expected outcomes

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

Respect

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

Privacy for detainees is limited. There is no screening between custody desks in the booking-in areas to protect detainees’ privacy. The suites are noisy when busy which makes communication between custody staff and the detainee difficult. There is no discreet booking-in area at either custody suite. However, detainees are offered the opportunity to speak to someone in private for any sensitive matters.

There is CCTV coverage in the suites and cells. Custody staff tell detainees about this but explain the toilet area is obscured from view. CCTV monitoring screens can’t be seen by detainees or others from the communal custody areas.

Showers aren’t private enough. Detainees can be seen from corridors as the doors are too low. Staff try to minimise this by closing corridors when in use and by discreet supervision. One shower in Melksham has a higher door that does provide sufficient privacy.

Detainee dignity is generally protected. Detainees are usually suitably dressed when moving about the suite and attending interviews. They are provided with adequate replacement clothing when necessary.

Meeting diverse and individual needs

Custody staff understand how to meet the individual needs of detainees and those from protected or minority groups. They generally do their best to meet these.

The suites have some facilities for detainees with disabilities or impaired mobility. Adjustments in the suites include:

• wheelchairs that are in good condition;
• step-free access to the exercise yards;
• an adapted toilet at each suite;
• extra thick mattresses to raise the bench if needed;
• hearing loops (although staff aren’t aware of them); and
• rights and entitlements in easy-read formats.

Provision for visually impaired detainees is more limited. Neither suite has sightlines in cells (markings to help visually impaired people judge the positioning of walls and obstructions), although rights and entitlement information is available in Braille.

Staff have a reasonable awareness of neurodiversity and how it affects detainees. Two cells in Melksham are painted in different colours to create a better environment for detainees with these needs and help them cope while in custody. There are also distraction activities in the suites.

Detainees are routinely asked on booking-in whether they have caring responsibilities that need to be considered while they are in custody.

Girls are allocated to the care of a female member of staff, but female adults aren’t. Menstrual care needs are generally well catered for with a range of products available. However, product disposal is unsatisfactory with used products being left in the cell until detainees leave custody. There is a sink available for handwashing in the cells, but detainees have to ask for soap.

There is good awareness of transgender detainees, and the staff we spoke to described appropriate care.

Provision for detainees who speak little or no English is variable. The force has recently changed interpreting services and staff told us they struggled to obtain an interpreter for some languages with the new provider. Conversations are conducted over a speakerphone at the custody desk. This gives no privacy and it is difficult to hear when the area is busy. The force told us it had provided two-way handsets in custody to improve privacy and ease of communication but none of the staff we spoke to were aware of these. Staff give rights and entitlements information in different languages to detainees who need this.

Detainees who wish to observe their faith are well provided for. Religious needs are identified during the booking-in process. There is a good range of religious books stored respectfully. At Melksham there is written guidance for staff on handling the Qur’an.

Risk assessments

Risk identification is generally good, but there are some weaknesses with its ongoing management and some practices aren’t in line with APP guidance. This means the force can’t ensure the safety of all detainees.

Most detainees are booked into the custody suites promptly. There are sometimes delays when the suite is busy and detainees wait in holding rooms or van docks before their detention is authorised. Custody officers told us they didn’t manage queues and don’t assess risks or injuries or prioritise booking in children or vulnerable adults.

Custody and detention officers focus appropriately on identifying risks, vulnerability factors and welfare concerns. They interact well with detainees and often ask relevant supplementary and probing questions. But sometimes they don’t explain the purpose of the risk assessment well enough to the detainee. They crosscheck computer systems and any previous custody records comprehensively for information to help identify additional risk. But custody staff rarely ask the arresting officers if they have any other relevant information to add.

Observations of detainees are mostly set at a level which reflect the risks presented. However, not all detainees under the influence of alcohol and/or drugs are placed on level 2 observations and rousal checks as per APP guidance. When level 2 observations are set correctly, rousal checks are generally completed well and do meet APP guidance. The detail of these checks is accurately recorded. The same staff complete rousal checks. This is important as it makes it easier to establish changes in a detainee’s behaviour or condition when under the influence of alcohol or drugs.

Level 1 checks (which don’t involve rousing a detainee) are carried out on time and appropriately through an open hatch. But the recording of these relies on pre‑populated text rather than tailored commentary, with little or no detail about any communication with the detainee. As with rousal checks, the same member of staff carries out these checks. This is good practice and follows APP guidance.

When a heightened level of risk is identified, detainees are placed on level 4 close proximity observations. The officers responsible for these observations should be briefed by the custody officer about the specific risks the detainee presents, and the detail should be documented in the custody record. This doesn’t always happen.

All custody officers remove footwear and clothing with cords from detainees regardless of the presenting risks, rather than making an individual risk assessment to decide if this is necessary. This doesn’t follow APP guidance and the justification for the removal isn’t documented in the custody record.

When anti-rip clothing is used to manage detainees at risk of self-harm, we found its use was proportionate to the risks posed and justified appropriately in the custody record.

Handovers between custody staff are very good and show considerable improvement since our last inspection. They include all incoming and relevant outgoing staff including healthcare staff. Handovers are formally conducted, using detailed custody record information and are properly focused on risk. Following handovers, the custody officer visits and takes time to speak with all detainees in their care. At the same time, they check the entire custody suite to make sure all facilities are satisfactory.

Cell call bells are audible and responded to promptly on the intercom system. All staff carry anti-ligature knives which is good practice and also an improvement since our last inspection. The management of cell keys is good with custody staff always having control over them.

Individual legal rights – detention

Detainees are generally booked into custody promptly. There are sometimes delays when more than one person is waiting.

Detention is appropriately authorised. Arresting officers provide the circumstances of the arrest and explain the grounds for why it is necessary well (as required by PACE Code G). Custody officers appropriately refuse detention if there are insufficient grounds to justify it.

When detention officers book detainees into custody there is appropriate oversight by custody officers.

The force uses alternatives such as voluntary attendance interviews, cautions, restorative justice and community resolutions to divert people away from custody. Suspects invited for a voluntary interview at Swindon attend facilities outside the custody suite. But at Melksham they are taken into the custody suite to use an interview room. This means they are exposed to the custody environment when the intention is to avoid this. The force has recently started monitoring the number of voluntary attendance interviews so it can assess how well it is using this as an alternative to custody.

Some detainees spend longer than necessary in detention waiting to be interviewed. We observed some detainees waiting over 12 hours before their interview. Delays are caused by waits for legal representatives, AAs, or interpreters.

When investigations can’t be completed during the first period of detention, detainees are bailed or released under investigation. We saw bail appropriately authorised and any bail conditions or restrictions commensurate to the offences under investigation.

In the year 1 November 2021 to 31 October 2022, the number of immigration detainees increased by 21 compared to the same period the previous year, according to information given to us by the force.

The force monitors how long immigration detainees spend in custody before they are transferred to immigration detention facilities. This shows an average of 12 hours and 51 minutes in custody after the immigration papers (IS91) are served. Custody staff reported good working relationships with immigration services.

Individual legal rights – detainees’ rights and entitlements

Custody and detention officers give good explanations to detainees about their rights and entitlements. These include:

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

They give detainees a two-page leaflet titled Remember your rights whilst detained. This has detailed information about things such as how to get information about their detention and what their entitlements are for welfare and personal needs. When people are detained in custody for the first time, they are given a further leaflet. This provides more details about facilities in the cells, the investigation process and healthcare provisions should they feel unwell or need support with mental health or drug and alcohol problems.

Copies of the recent edition of the PACE Code C book (August 2019) are available at the suites. We saw staff routinely offer these to detainees when they were booked into custody.

There are copies of the easy-read version of rights and entitlements for children and other detainees who may need help to understand their rights. We saw these given to detainees when needed.

When a detainee declines free legal advice, we expect custody officers to explore the reasons for this. We saw some custody and detention officers do this and reminding detainees that legal advice is free of charge and they could change their mind and ask for it at any time. But it didn’t happen in some cases we observed.

We also expect legal representatives to be encouraged to represent detainees in person. We saw legal representatives attending in person and custody officers told us this was usually the case.

Posters advertising the right to free legal advice are clearly visible in the suites. Custody and detention officers we spoke to were aware of the requirements of PACE Code C Annex M (detainees should receive documents and records on important information about custody processes in a language they can understand). They knew where to find the translated documents on the force’s computer system and gave them to detainees who needed them.

There are enough interview and consultation rooms for detainees to privately consult with their legal representatives. Detainees wishing to speak to their legal representatives on the telephone can do so in private at Swindon, where there is a private telephone booth. At Melksham, detainees are given a mobile telephone in their cell while the detention officer remains outside to supervise its use. This doesn’t offer the same level of privacy. Legal representatives are given a copy of the detainee’s custody record when requested.

When detainees are held incommunicado (delaying their right to have someone informed of their arrest) this is appropriately authorised and removed when no longer required.

Detainees who are foreign nationals have the right to speak to somebody at their country’s embassy, consulate or high commission at any time and custody officers arrange this if requested. When custody officers are required to notify these bodies because an agreement exists with the relevant country, this also happens.

Detention officers tell detainees about the retention and destruction of any DNA samples that have been taken. DNA samples are stored securely and in freezers to maintain sample integrity. They are regularly collected from the suites.

Reviews of detention

Reviews of detention aren’t always carried out well enough, or in the best interests of detainees. Not all aspects comply with PACE and its codes of practice.

In addition, reviews of detention aren’t always carried out on time. Some are late and we found some detainees who didn’t have their detention reviewed at all. This is a breach of section 40 of PACE.

When reviews are carried out by telephone the reasons why the reviewing officer hasn’t attended in person aren’t clearly recorded as required by PACE Code C paragraph 15.14.

Too many reviews take place while the detainee is asleep. The reviews we examined weren’t always carried out in recognised rest periods and the detainee should therefore have been woken and spoken to. Some custody record entries indicated the detainee was awake immediately before or after the review. Detainees were generally told that a review had taken place while they were asleep and notices are displayed on most cell doors to remind officers to do this. However, this didn’t always happen at the earliest opportunity (as required by PACE Code C paragraph 15.7).

The standard of reviews varies. In some cases, continued detention was authorised without giving detainees the opportunity to make any representations (as required by PACE Code C paragraph 15.3). And there wasn’t always enough emphasis on assessing the progress of the investigation.

However, in the reviews we saw, detainees were spoken to courteously, and sufficient care was given to their well-being, such as whether they had been provided with enough food and drink and had any other needs met.

Complaints

Notices outlining the procedure for detainees to make complaints are prominently displayed at the custody suites. Information about how to make a complaint is also provided in the Remember your rights whilst detained leaflet.

Independent Office for Police Conduct leaflets are available which provide contact details about making a complaint to it.

Custody staff we spoke to were aware of the procedure and what to do if a detainee makes a complaint.

Section 4. In the custody cell, safeguarding and healthcare

Section 4: Expected outcomes

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

Physical environment

Wiltshire Police has two designated suites at Melksham and Swindon. The force owns the buildings housing the suite at Melksham, and the suite at Swindon is provided through a private finance initiative with an external company.

There are potential ligature points in both suites, mainly in the exercise yards and areas around the shower.

In Swindon, every cell also has potential ligature points. And the doors in every cell but one don’t meet current design standards because they don’t have adjustable and removable door keeps that provide easy access in the event of an emergency. During the inspection we gave the force a comprehensive illustrative report detailing these findings as well as the physical conditions in the suites more generally.

At both sites, the ventilation and temperature in the suites and individual cells are satisfactory and there is some natural light in the cells. All cells have toilets and sinks for handwashing and signs outside the cells advise detainees that the water isn’t suitable for drinking.

Cleanliness across the suites is good. Deep cleans of suites are carried out once a year. Staff told us that repairs are mostly completed quickly. There was little graffiti, and where there was it was in the exercise yards.

There are no discrete booking-in areas or glass-fronted cells to help those who experience claustrophobia. The holding areas for detainees are separate from the booking-in areas.

Custody staff told us they carry out regular checks of the suite to inspect conditions. But these walk-throughs haven’t found the ligature points we identified.

CCTV operates in the suites. There are signs telling detainees about this, but these aren’t always placed where detainees can easily see them. The quality of the footage is poor, especially at Melksham, and there isn’t audio coverage for some areas. However, coverage of toilets in cells is appropriately pixelated.

The CCTV screens are positioned so that they can’t be viewed by detainees or others in the custody area.

Both suites have a room where level 3 CCTV observations can be carried out. However, we saw officers sitting in the custody desk area to do these, which means they can become distracted from these duties.

Generally, there is a good understanding of emergency evacuation procedures. Staff we spoke to had received recent fire safety training and this included a practical fire evacuation. Fire evacuation boxes are present in both suites, with enough handcuffs and other equipment to manage an evacuation.

Use of force

When force is used on detainees in custody it isn’t always managed well. There is poor recording of the use of force in custody.

We reviewed 23 cases of use of force on CCTV. When force was used, in most cases it was proportionate to the risk or threat posed. But incidents weren’t always managed well. And custody officers didn’t always oversee and direct the use of force well enough.

However, we also saw some good communication by officers which de-escalated situations well and avoided the need to use force.

Restraint techniques were usually deployed correctly. But we saw officers failing to appropriately control the situation. This resulted in an escalation of the incident and further force being used, and increased the risk of injury to the detainee.

In some of the cases we reviewed, force was used to remove a detainee’s clothing or other items. It wasn’t always clear from custody records or our observations on CCTV, that the removal was necessary and justified. In our view, it led to using force that could potentially have been avoided. In addition, officers didn’t always maintain the detainee’s dignity well when removing the clothing.

We referred four cases to Wiltshire Police for learning. One involves poor techniques and use of force which risked injury to the detainee. Two cases involve potential self‑harm incidents and it isn’t clear how these were subsequently taken account of in the detainee’s risk assessment and care plan. The fourth case relates to the assessment of risk and the use of force resulting in a minor injury to the detainee. We also referred a case as a good example of the safe application of force and restraint techniques.

Officers who use force on detainees in custody don’t always submit individual use-of-force forms as required by National Police Chiefs’ Council guidance – despite often being reminded to do so by custody officers. We asked for use-of-force forms for the incidents we reviewed but in some cases we received no forms, and in most of the remaining cases we didn’t receive all the forms we were expecting.

Use-of-force incidents aren’t always included on the custody record. When force is recorded the details are sometimes limited.

Custody officers review some use-of-force incidents for quality assurance and to learn from them. However, our review of incidents identified themes which don’t seem to have been recognised by the force, so it isn’t clear how effective these arrangements are.

These limitations make it difficult for Wiltshire Police to show that when force is used in custody it is necessary, justified and proportionate. And it doesn’t provide confidence that all use-of-force incidents are properly identified, with no under recording.

Handcuffs aren’t always removed quickly enough from compliant detainees. The reasons why handcuffs have been used or the time they are removed aren’t recorded.

We found that the necessity and justification for a strip search was adequately recorded on the custody records we reviewed. Strip searches were managed well but the dignity of the detainee wasn’t always considered.

Most custody officers and all custody detention officers are up to date with their officer safety training. Training is scheduled for those that aren’t.

Detainee care

The approach to detainee care is good.  Detainees spoke positively about the care they received, and most were aware of the facilities available to them. Custody staff tell detainees about their entitlements to food and drink, showers, exercise and reading materials when they are booked into custody.

Food and drinks are offered and provided regularly. The food preparation areas are clean and well equipped. The range of food is reasonable and meets most dietary requirements. It includes instant porridge, microwave meals, tea, coffee and hot chocolate as well as squash and water.

Distraction materials such as foam balls, colouring books and fidget poppers are available. Foam balls are given out regularly. However, we didn’t see the other distraction materials handed out often.

The range of reading materials is extensive and includes children’s books and foreign language titles. But we found few detainees were offered these.

Showers are offered but it depends on how busy the suite is. Detainees are given toilet paper when they go into their cell. There is a good range of toiletries and menstrual care products for detainees.

Exercise is offered sporadically, again depending on how busy the suite is. Both suites have exercise yards with partial coverage for inclement weather.

There is a good supply of replacement clothing, including underwear and footwear, for detainees that require it. These are available in different sizes.

All cells are equipped with a mattress and a pillow, and extra-thick mattresses are available at both suites. The quality, cleanliness and conditions of the mattresses across the custody estate is generally good.

Safeguarding children and vulnerable people

Custody staff and police officers have a good understanding of their safeguarding responsibilities for children and vulnerable adults. Training has been given to help them identify safeguarding concerns, for example by recognising when children are involved in drugs offences because of county lines activities, and what they should do.

Custody staff interact well with children and vulnerable adults. They take account of safeguarding concerns and make appropriate arrangements for them while in custody and on their release.

Arresting or investigating officers make safeguarding referrals to partner agencies for children and vulnerable adults. We examined children’s cases and this had happened in most of them. The referrals were comprehensive and recognised the risks posed to a child such as criminal exploitation or modern-day slavery.

However, in the custody records we examined not all children had seen either an HCP or L&D worker. This limits the opportunity for safeguarding needs to be recognised and for support to be provided.

Children and vulnerable adults are released to the care of their family. Where this isn’t possible, or there are safeguarding concerns preventing this, alternative arrangements are made to ensure their safety and well-being.

Appropriate adults

Children generally don’t wait too long before receiving support from an appropriate AA, but this isn’t always the case for vulnerable adults.

In most cases, custody staff request AAs early on in a child’s detention but there are sometimes delays before they receive support. However, requests for AAs for vulnerable adults aren’t always made quickly enough and sometimes attendance is arranged for the time of the interview. This means the detainee doesn’t receive early support about their rights and entitlements and overall welfare needs.

Family or friends are contacted in the first instance to attend as AAs. If this isn’t possible other arrangements are made. Staff from the Youth Justice Service or trained and vetted community volunteers attend for children and The Appropriate Adult Service provides AAs for vulnerable adults. At night, the local authorities’ emergency duty service is expected to provide an AA for children. If this isn’t possible, an AA can be requested from The Appropriate Adult Service. The force monitors AA attendance for children.

Custody staff are aware of their responsibilities to secure an AA when a detainee is vulnerable. But in some cases we examined, there was information to suggest that an adult was vulnerable and an AA should have been considered but wasn’t.

A leaflet produced by the National Appropriate Adult Network is available in the suites to provide guidance to AAs about their role in actively protecting the detainees’ rights. Similarly, a booklet is available to those needing an AA to understand their role and the help and support they offer.

There are rooms in both the suites so that an AA can speak to a child or vulnerable adult at any time and in private.

Children

Children are only detained as a last resort. Their detention is closely scrutinised to make sure it is appropriate, and in general their cases are dealt with quickly. Bail or releasing children under investigation is used appropriately to keep their time in custody to as short a time as possible. However, some reviews of detention for children could be better as these don’t always consider their particular circumstances and needs.

Children are generally well cared for in custody. Female staff are assigned to care for girls (as required by the Children and Young Persons Act 1933). There are distraction activities and devices to help children cope better. Children and their AAs are also allowed to stay in a room adapted for those with neurodiverse conditions rather than remaining in a cell. This offers a good environment for children to stay in.

Few children are charged and remanded. Those that are aren’t moved to alternative accommodation as they should be, despite escalation processes and discussions with children’s social care.

Between 1 November 2021 and 31 October 2022, 719 children were brought into custody, according to information provided by the force. Of these, 14 children were charged and refused bail. Alternative accommodation was requested in 12 of the 14 cases, but only 1 child was transferred to local authority accommodation and 1 child was returned home by the local authority. The rest of the children remained in custody overnight because no accommodation was available.

There are escalation processes, but these are rarely successful due to a lack of alternative accommodation. In the cases we reviewed, custody officers completed juvenile detention certificates which clearly show why the child had remained in custody.

The force closely monitors children in custody. It discusses cases with local authority partners which include children who have been:

• strip searched;
• held for long periods (including overnight); and
• charged, remanded and required alternative accommodation.

Healthcare

Mitie Care & Custody is contracted to provide physical healthcare support to detainees and carry out forensic testing in custody. This contract began six weeks before the start of the inspection and the service was still being implemented when we visited. Staffing shortages meant HCPs weren’t embedded in each suite and healthcare for detainees was adversely affected. Senior HCPs were covering staffing gaps as best they could and there was ongoing recruitment to vacancies.

Although the Mitie Care & Custody contract is new, robust governance procedures have been established for monitoring the safety, quality and performance of services. Where the service isn’t provided as required the force can apply ‘financial credits’ (penalties). Mitie Care & Custody meets with the force weekly to share data and there are monthly contract review meetings which help assess performance.

Avon and Wiltshire Mental Health Partnership NHS Trust (AWP) is commissioned by National Health Service England to provide L&D services across Wiltshire custody suites. Staff from Mitie and L&D meet daily to share information about detainees’ healthcare although there aren’t yet formal arrangements for the teams to meet routinely.

HCPs and L&D workers receive relevant training for their roles and an annual appraisal of their performance. Both teams are up to date with clinical supervision.

Infection prevention and control standards have improved since the last inspection. Clinic rooms are cleaned to an appropriate standard, and flooring has been replaced at Swindon. Further improvements are needed at Melksham, but the planned refurbishment in early 2023 should address these. A separate room is used for forensic sampling at each suite and is forensically cleaned before and after examinations.

Medical rooms have essential emergency equipment and all suites have easily accessible police-owned automated external defibrillators. Equipment is regularly checked to ensure it is fit for purpose and ready for use.

Healthcare staff can access interpretation services for those detainees whose first language isn’t English.

Staff from both health providers report incidents through their electronic reporting systems. Incidents are investigated and learning is shared with staff. Outcomes of investigations are reviewed and shared with the force as part of regular contract monitoring meetings.

Both providers have a confidential complaints process. There have been few complaints recently. However, information for detainees about how to make a health‑related complaint isn’t displayed prominently, as we would expect.

Physical health

Staffing shortages mean detainees aren’t always seen promptly by HCPs and some aren’t seen at all before leaving custody. This doesn’t meet the detainee’s rights to healthcare. Routine monitoring of detainees doesn’t always take place as it should and detainees don’t always receive their medicines at the required time. This poses significant risks to detainees, Mitie Care & Custody and the force. It is a cause of concern that the force needs to address urgently.

HCPs should be embedded in both custody suites, but vacancies mean staff are required to travel between suites leaving one with no cover. At the time of our inspection, five new staff were waiting to start.

However, HCPs are experienced and competent practitioners who treat detainees respectfully and carry out comprehensive assessments of their health needs.

HCPs receive appropriate training for their roles and contribute to decisions regarding risk and fitness to detain, interview or release. However not all staff have been able to learn Mitie’s policies and processes and staff told us this was because they are too busy providing the service.

Staff complete clinical assessments and examinations in dedicated clinical rooms. Depending on the assessed risk, the door to the clinical room is left ajar rather than open. The service employs both male and female HCPs and, where possible, an assessment is carried out by an HCP of the gender requested by the detainee.

Staff seek consent from detainees for healthcare interventions and capacity is assessed and recorded clearly where appropriate. There are protocols which allow healthcare staff to share appropriate information with custody staff.

Staff assess a range of needs including physical and mental health, substance misuse, safeguarding and social needs. The clinical records we reviewed were comprehensive and contained a plan of care that reflected the assessed needs of the detainee, meaning care is safe and appropriate.

Staff complete paper clinical records for detainees and store these securely. Mitie Care & Custody is implementing an electronic clinical system, but staff aren’t yet trained to use it.

HCPs update the custody record so that custody staff have an up-to-date view of the healthcare needs of the detainee and are aware of identified risks. They can then take account of these to care for the detainee in custody and on release.

Mental health

The L&D service provided by AWP covers all types of vulnerabilities. Dedicated and skilled staff provide good support to vulnerable detainees arriving in custody. This includes support with housing, social problems and drug and alcohol issues. L&D staff work in the suites 7 days a week, 8am to 8pm. The HCPs provide acute and out-of-hours mental health support as part of their role.

L&D staff screen detainees entering custody. They prioritise assessment for those referred by custody staff because of mental health or well-being concerns, and those in specific groups such as women, veterans or people with a learning disability.

Women are offered a specific pathway scheme that offers support to divert them away from the criminal justice system. The Nelson Trust is subcontracted to provide this care for women. All women in custody are offered help. They can drop into a support hub and get help with gambling addiction, domestic abuse, emotional support, housing, employment and benefits.

AWP invests in and runs a programme for people with lived experience to become peer mentors. This offers support to detainees, with referrals made based on individual need.

Mentors help the detainee to access community services, education, training and employment. In the 12 months before our inspection, 12 detainees were referred to a peer mentor and 10 accepted help.

Support time and recovery workers also meet detainees in custody. They can talk to family members, help with community appointments and support detainees at court.

When children come into custody the L&D staff contact the local children and adolescent mental health service to share information and make referrals. Staff told us they don’t feel qualified to offer direct specialist support to children in custody but will offer some interim advice and help. AWP is actively recruiting a specialist worker to improve the service for children.

The L&D staff can read the custody record and record all relevant health information onto it. This means the custody records are up to date with detainee needs and care.

Staff, including L&D staff based in the courts, attend weekly virtual team meetings to help the service assess risk, make decisions and allocate staff appropriately across the custody suites to meet detainee needs.

The L&D team record good detail in AWP’s electronic record system so actions and outcomes are shared with partner agencies. We reviewed a small sample of clinical records and found staff completed comprehensive assessments of detainee needs. Records also included interventions offered by community engagement workers following referral from the L&D staff. This makes sure there is clear oversight of the healthcare and support given to detainees while in custody and following release.

Since our last inspection, the use of section 136 of the Mental Health Act 1983 has increased. In the 12 months prior to this inspection, section 136 was used on 395 occasions. In three cases, custody was used as a place of safety because of exceptional circumstances. The remaining detainees were taken to health-based places of safety.

Six mental health clinicians provide 24/7 cover in the force control room. AWP’s level of commitment to this role is very positive. The clinicians have access to force systems and clinical information, and they support frontline officers to decide the best action to take when dealing with someone with mental ill health. For the period 1 January to the 31 October 2022, the mental health control room triage service responded to a total of 7,546 calls across Wiltshire and Swindon.

However, section 136 is being increasingly used to transfer detainees with suspected acute mental health problems from custody to a health-based place of safety for an assessment. In the year ending 31 October 2022, it was used on 55 occasions for adults, including for a child in 1 case. This might suggest some detainees are taken to custody despite being mentally unwell.

Some detainees with suspected acute mental health problems remain in custody for a Mental Health Act assessment. These are generally carried out promptly. Between 1 November 2021 and 31 October 2022, 25 detainees were referred and waited an average of 4.45 hours for an assessment and a further 3.57 hours for a bed to become available.

The force faces significant challenges in accessing beds at health-based places of safety in Wiltshire. This can result in delays in getting detainees the support they need.

Substance misuse

HCPs provide initial assessment and, where required, treatment for detainees experiencing drug and alcohol withdrawal while in custody. HCPs use nationally recognised assessment tools to monitor and inform decision-making about withdrawal. Staff administer medicines to relieve symptoms of withdrawal, as clinically indicated. The care records we reviewed reflected appropriate clinical decision-making and clear treatment care plans for those experiencing withdrawal.

Criminal justice workers from Turning Point come into custody every morning and talk to each detainee regardless of whether they have disclosed any issues to custody staff. This includes seeing children, who they refer to Motiv8 (a substance misuse service for young people aged 11 to 18 years old in Wiltshire). Detainees are offered harm minimisation advice, needle exchange and information about services. Turning Point also run a drink driving awareness campaign with the road safety team each December. Turning Point staff feel they have a good working relationship with custody staff and the HCPs at each suite.

HCP staff support detainees already in treatment in the community to continue opiate substitute treatment while in custody, subject to confirmation of ongoing compliance.

Medicines management

Staff provide a range of care and treatment interventions suitable for detainees, and consistent with national guidance and best practice. The service has several patient group directions to support staff with decision-making for a range of health issues, including acute withdrawal from alcohol and drugs. Nicotine replacement therapy is provided by custody staff.

Mitie has robust governance arrangements to manage medicines. HCPs use systems and processes to safely administer, record and store medicines. They manage controlled drugs appropriately and complete regular audits of medicines to identify any potential errors. Staff report medicine errors through the electronic reporting system and managers investigate these promptly. Custody staff store detainees’ own labelled medicines in the detainee’s property locker.

HCPs administer medicines to detainees but staffing shortages mean this doesn’t always happen at the required time.

Custody staff make provision for detainee medicines to be transferred to court or other agencies.

Section 5. Release and transfer from custody

Section 5: Expected outcomes

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

Safe release and transfer arrangements

Custody staff generally have a clear focus on making sure detainees are released safely. We saw a good level of care given to detainees on release.

Custody officers assess the detainee’s risks when they are released but don’t always fully complete the pre-release risk assessment with the detainee present. This doesn’t follow APP guidance and doesn’t ensure all risks identified during detention are considered or discussed with the detainee before their release or transfer. Pre-release risk assessments don’t always record all the available information, such as substance misuse and addictions.

Custody staff are supportive and help detainees to travel home safely. They provide access to telephone calls, bus or train information and issue travel warrants if required. Police officers often take detainees home, particularly children or vulnerable adults.

People who are bailed are given good explanations about what this means and any conditions they must comply with. Staff also explain to those released under investigation the possible offences they may commit if they interfere with victims or witnesses while the investigation is ongoing.

Most custody officers are aware of enhanced safeguarding arrangements for those arrested on suspicion of committing sexual offences. But the details of any enhanced risk assessment aren’t always recorded in the custody record on release.

There is good support agency information available, with a leaflet handed out to all detainees on release or placed in the property of those transferring to court. We saw custody officers give a good level of care. For example, we saw cases where officers explained to vulnerable detainees which support agency could help them most.

Detention officers complete digital person escort records and book transport for detainees attending court. These forms are mostly completed well and record risk, health and medical information. However, the custody officer responsible for releasing the detainee doesn’t always check or sign off these forms, as required by APP guidance.

Courts

When detainees are remanded, they are generally transferred promptly to the next available court. Detainees appear before the local court in person, although virtual court facilities are available if needed.

Detainees who are remanded or arrested on warrant during the day are sometimes able to appear before the court later the same day. This minimises their time in police custody and has improved since our last inspection.

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

Causes of concern and recommendations

Areas for improvement

Leadership, accountability and partnerships

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

In the custody cell, safeguarding and healthcare

Release and transfer from custody

Section 7. Appendices

Appendix I – Methodology

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

Document review

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

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

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

Data review

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

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

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

Custody record analysis

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

Case audits

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

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

Observations in custody suites

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

Interviews with staff

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

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

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

Focus groups

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

Feedback to force

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

Appendix II – Inspection team

• Norma Collicott: HMI Constabulary and Fire & Rescue Services inspection lead
• Patricia Nixon: HMI Constabulary and Fire & Rescue Services inspection officer
• Anthony Davies: HMI Constabulary and Fire & Rescue Services inspection officer
• Ian Smith: HMI Constabulary and Fire & Rescue Services inspection officer
• Emmanuelle Versmessen: HMI Constabulary and Fire & Rescue Services inspection officer
• Marc Callaghan: HMI Constabulary and Fire & Rescue Services inspection officer
• Vijay Singh: HMI Constabulary and Fire & Rescue Services inspection officer
• Andy Reed: HMI Constabulary and Fire & Rescue Services inspection officer
• Stephen Matthews: HMI Constabulary and Fire & Rescue Services inspection officer
• Martine Moore: HMI Constabulary and Fire & Rescue Services inspection officer
• Lynda Day: CQC inspector

Fact page

Note: Data supplied by the force.

Force

Wiltshire

Chief constable

Kier Pritchard

Police and crime commissioner

Philip Wilkinson

Geographical area

Wiltshire and Swindon

Date of last police custody inspection

2016

Custody suites

• Swindon: 39 cells
• Melksham: 19 cells

Annual custody throughput

November 2021 to 31 October 2022

• Swindon: 4,386
• Melksham: 3,977
• Total: 8,363

Custody staffing

• 1 inspector head of custody
• 1 sergeant – strategic support/deputy head

Swindon:

• 8 custody sergeants
• 18 detention officers (of which 5 are part time)

Melksham:

• 9 custody sergeants
• 20 detention officers (of which 6 are part time)

Health service provider

Mitie Care & Custody

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Report on an inspection visit to police custody suites in Wiltshire