Report on an unannounced inspection visit to police custody suites in West Mercia

Summary

This report describes our findings following an inspection of West Mercia 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 January 2022. It is part of our programme of inspections covering every police custody suite in England and Wales.

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

This inspection took place during the COVID-19 pandemic. We continue to adapt our ways of working to manage the risks as the pandemic continues. We gave the force more notice of the inspection than usual. And we carried out our case reviews and analysis, interviews and focus groups remotely. We made our observations over the two-week period, but we limited the number of our inspectors in the suite at any one time.

We last inspected custody facilities in West Mercia Police in 2014. At that time West Mercia provided its custody services in collaboration with Warwickshire Police. Our recommendations applied to both forces, but for this inspection we have assessed West Mercia’s progress against those recommendations. We found that of the 29 recommendations made during the 2014 inspection, the force has fully or partially achieved 19.

To help the force improve, we have made recommendations to it (and the police and crime commissioner). These address our main causes of concern. We have also highlighted a further 11 areas for improvement. These are set out in section 6 of this report.

Leadership, accountability and partnerships

We last inspected West Mercia Police custody arrangements in October 2014, when the force was formally collaborating with Warwickshire Police under section 22 of the Police Act 1996. These arrangements ceased in 2019.

West Mercia Police has a clear governance structure for the safe and respectful provision of custody services, but the arrangements aren’t resulting in good custody services. Our inspection identified some critical weaknesses in how custody is provided to make sure detainees are kept safe and treated and cared for well. Some of the recommendations from our last inspection haven’t been achieved and some important areas of custody now require urgent attention – including management oversight of custody, meeting legal requirements, governance and oversight of the use of force, risk management and detainee care. These are now causes of concern.

The force responded quickly to our findings during the inspection, taking action in several areas. This gives us confidence that custody services, and outcomes for detainees, will now improve.

Our observations in the suites showed that custody staff aren’t always used in the most effective way. They aren’t always carrying out tasks most suited to, or appropriate for the responsibility of their role – for example detention officers are recording changes to detainee observation levels when this is the custody officer’s responsibility. Authorised Professional Practice (APP) and force policies aren’t always followed and there are inconsistent practices throughout the suites.

The force monitors some important areas of custody provision but there are some gaps. It could provide much of the information we asked for. But some isn’t collected, for example waits for Mental Health Act assessments, and some is inaccurate, for example information on the use of force. The quality of recording on custody records is generally poor, so it is difficult to assess how well detainees are treated and cared for in custody.

However, adverse incidents in custody (an adverse incident means any incident which, if allowed to continue to its ultimate conclusion, could have resulted in death or serious injury to any person) are reported and recorded well. Learning from these incidents is shared.

The force doesn’t always meet the requirements and guidance as set out in the Police and Criminal Evidence Act 1984 and its codes of practice and other legislation. For example, it doesn’t always inform detainees when a review has taken place while they were asleep as required by paragraph 15.7 of PACE Code C.

The force cannot show that when force or restraint is used in custody it is necessarily justified and proportionate. Information on the use of force is inaccurate, not all officers complete use of force forms as required, CCTV footage of incidents is limited and of poor quality and there is no, or limited, recording on custody records about any force used. However, in the use of force cases we looked at on CCTV appropriate techniques were used.

The force understands the public sector equality duty and monitors disproportionality in some custody services to assess whether outcomes for detainees are fair. Custody staff routinely ask detainees to self-define their ethnicity to support this approach.

West Mercia Police are open to external scrutiny from Independent Custody Visitors who regularly visit suites. Custody staff are responsive to addressing any concerns.

Working relationships between the force and its local authority and health partner organisations are generally good. But limited resources make it difficult to meet the needs of children and those with mental ill health.

Pre-custody: first point of contact

Frontline officers we spoke to all had a good understanding of what makes a person vulnerable. They take account of this when deciding whether arrest is the most appropriate action. Children are only taken to custody as a last resort.

Information about individuals to help officers make arrest decisions isn’t always as good as it should be, especially when dealing with people with mental ill health. This limits officers’ ability to explore whether alternatives to arrest are appropriate.

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

Custody officers generally treat detainees respectfully, and deal with them patiently. Privacy for detainees is hindered by the design of the suites and conversations can sometimes be overheard, especially at busy times. Some custody practices don’t protect the dignity of detainees, such as the routine removal of footwear without providing replacements.

The individual and diverse needs of detainees aren’t met consistently. People with disabilities or impaired mobility aren’t catered for well, religious materials to allow detainees to observe their faith while in custody are limited, interpretation services aren’t always used, and the needs of women could be better met. However, staff are aware of how they might meet the needs of people who are neurodivergent and those who are transgender.

The approach to identifying risk is generally good and custody officers set appropriate observation levels. But there are significant weaknesses in its management. Some working practices mean that the force isn’t always making sure that detainees are kept safe. Observation checks on detainees aren’t always carried out well, the frequency of checks is sometimes reduced too soon, and many practices don’t follow APP guidance. Custody officers continue to routinely remove detainees’ clothing rather than deciding whether to do so according to an individualised risk assessment, and rip-proof clothing is frequently used without sufficient justification.

Custody officers appropriately authorise detention for detainees entering custody. However, cases aren’t always progressed as quickly as they could be and some detainees, including children, spend a long time in custody.

Custody officers generally give good explanations to detainees about their rights and entitlements. But detainees aren’t always given the ‘Rights and Entitlements’ leaflet, or actively offered the PACE Code C booklet, as required by PACE Code C.

Reviews of detention aren’t always carried out well or in the best interests of the detainee. The quality of these reviews varies and some aspects of them don’t meet the requirements of PACE Code C.

Detainees released under investigation are given a notice outlining the possible offences they may commit if they interfere with victims or witnesses while the investigation is being conducted. We also saw oral explanations being given to detainees.

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

In the custody cell, safeguarding and health

General conditions throughout the five suites vary due to their age and the design of the buildings. Cells are reasonably well maintained, but cleanliness requires improvement. There are potential ligature points (which can be used by a detainee to self-harm) in most suites, mainly due to the design of toilets, sinks and some loose hatches. A comprehensive illustrative report detailing these, and general conditions, was provided during the inspection. The force responded positively to this, taking immediate action to remedy the problems highlighted.

The overall approach to caring for detainees in custody is poor. Detainees we spoke to held mixed views about their treatment. Custody officers explain that food, drinks, showers, exercise and reading materials are available when detainees are booked into custody, but after this offers are limited, and often depend on detainees asking. Food and drinks aren’t regularly offered even at mealtimes.

Officers we spoke to have a good awareness of their safeguarding responsibilities and how to make referrals to other agencies. Support from appropriate adults (AAs) for children and vulnerable adults in custody isn’t always good enough. Some detainees wait a long time before receiving any support and AAs aren’t always considered for vulnerable adults.

Some children are cared for well in custody and given distraction activities to reduce their anxiety. But there are few other arrangements and girls aren’t allocated a female member of staff to oversee their care as required by law. Some children are released quickly, but others spend a long time in custody and it isn’t always clear why. Local authorities are rarely able to provide accommodation for children charged and refused bail so they aren’t moved from custody as they should be.

Healthcare professionals (HCPs) are experienced and competent and offer a good standard of healthcare to detainees. The force generally manages the contract for the provision of health services well.

The liaison and diversion service based in custody provides good support to vulnerable detainees, especially those with drug and alcohol problems or with mental ill health. This includes arranging for support in the community after a detainee leaves custody.

Detainees sometimes wait in custody a long time when they need an assessment under the Mental Health Act 1983. Limited information and poor record keeping makes it difficult to know how detainees’ mental health needs are dealt with.

Release and transfer from custody

Good attention and care is given to detainees when they are released. Custody officers engage well with detainees to make sure risks are identified and addressed. There are arrangements to make sure detainees get home safely. Police officers frequently take children and vulnerable adults home if they cannot be released to the care of a responsible adult.

Detention officers complete electronic person escort records (ePERs) for detainees attending court or who have been recalled to prison. But custody officers don’t always check the content of these records or sign them off before a detainee leaves the suite, and most don’t complete any pre-release risk assessment with these detainees.

Good working practices between the force and HMCTS mean that detainees are generally presented before the first available court. This has improved since our last inspection and means most are held 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 our Expectations for Police Custody. These standards are underpinned by international human rights standards and are developed by the two inspectorates. We consult other expert bodies on them across the sector and they are regularly reviewed. This helps to achieve best custodial practice and drive improvement.

The expectations are grouped under five inspection areas:

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

The inspections also assess compliance with the Police and Criminal Evidence Act 1984 (PACE) codes of practice and the College of Policing’s Authorised Professional Practice – Detention and Custody.

The methodology for carrying out the inspections is based on:

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

We also analyse a representative sample of custody records from all suites in the force area for the week before the inspection starts. For West Mercia Police we analysed a sample of 112 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 West Mercia Police custody arrangements in October 2014, when the force was formally collaborating with Warwickshire Police under section 22 of the Police Act 1996. Under these arrangements the governance and oversight of custody services were shared. These arrangements ceased in 2019.

West Mercia Police has a clear governance structure for the safe and respectful provision of custody services. An assistant chief constable (ACC) has overall responsibility for custody services supported by a chief superintendent. A chief inspector is responsible for day-to-day management throughout the force’s five suites.

There are strategic and operational governance arrangements to oversee custody. A custody management meeting chaired by the chief inspector, and a custody steering group meeting chaired by the chief superintendent, discuss and monitor important areas of custody provision. Representatives from other parts of the force and from outside bodies attend these meetings. Custody matters are also considered at the local policing and operations meeting chaired by the ACC.

However, these arrangements aren’t resulting in good custody services. Our inspection identified some critical weaknesses in how custody is provided to make sure detainees are kept safe and treated and cared for well. Some of the recommendations from our last inspection in 2014 haven’t been achieved or have only partly been achieved, leaving some important areas of custody requiring urgent attention – including management oversight of custody, governance and oversight of the use of force, risk management and detainee care. These are now causes of concern.

More positively, the force responded quickly to our feedback during the inspection with action taken in several areas. This gives us confidence that custody services, and outcomes for detainees, will now improve.

Oversight of the healthcare contract is generally good so that detainees’ health needs are met.

The force provides custody services at five suites located in Worcester, Hereford, Telford, Kidderminster and Shrewsbury. The suites are staffed by 3 custody inspectors, 47 custody officers and 59 detention officers. The detention officers are employed by Bidvest Noonan under a contract with West Mercia Police.

Our observations in the suites showed that although staff are stretched at busy periods, there were generally enough of them to provide the services required. However, they aren’t always used in the most effective way. There is little supervision over activities in the suites and inspectors and custody officers have little direction over the work of the detention officers because Bidvest Noonan have their own supervision arrangements. This leads to inconsistent practices throughout the suites and sometimes between shifts, and to staff not always carrying out tasks they are most suited to and appropriate for the responsibility of their role. Our observations found the following:

• Detention officers record changes to observation levels, often without providing the reasons, when this is the responsibility of the custody officer.
• Some welfare checks, including rousals, are completed by officers conducting close proximity watches when detention officers should do this.
• Detainees are escorted to cells by arresting officers, when detention officers should do this.
• Custody officers are meeting some detainees’ care and welfare needs even when detention officers appeared to be available to do this.

Custody officers and detention officers receive three weeks’ initial training and are mentored by more experienced staff before taking up their role. Continuous professional development training has been limited, with only one day a year for custody officers, although this has recently been increased to three days every two years. The training has included awareness of mental ill health, updates regarding bail and dealing with children in custody. Detention officers aren’t included in CPD training. Instead, their supervisors attend the training and are expected to brief their staff. But there is little monitoring to make sure this happens – this was an area for improvement in our last inspection.

The force has adopted the College of Policing’s Authorised Professional Practice (APP). It also has its own custody policies and guidance, but these aren’t always followed, and we found that not all custody and detention officers had enough knowledge about what APP requires. This contributes to the inconsistent practices that we observed throughout the suites, for example how the weekly health and safety checks are carried out and who is responsible for them, and how detainee risks are managed.

There have been no deaths in custody since our inspection in 2014, but one detainee died following release from custody in Hereford in 2017. In line with nationally set requirements the force referred this case to the IOPC for investigation.

Accountability

Performance is monitored at the meetings described above. Information on the number of detainees entering custody, voluntary attendance, children in custody and strip searching is looked at. The force could provide much of the information we asked for, but some important information is missing, for example, the time children and vulnerable adults wait for support from an appropriate adult, waiting times for mental health assessments, and how long those in mental health crisis remain in custody. This information is often not recorded clearly on custody records, so the force can’t determine how well it is meeting detainee needs. Some information is inaccurate, especially for when force is used in custody.

Staff report and record adverse incidents that happen in custody well. We saw examples of this. Learning from incidents is shared directly with staff involved and with other staff through a regular custody newsletter, ‘The relevant times’.

The force doesn’t always meet the requirements and guidance as set out in the Police and Criminal Evidence Act 1984 and its codes of practice and other legislation. This is a cause of concern. For example:

• Detainees aren’t informed when a review has taken place when they were asleep (15.7 PACE Code C).
• Not all detainees are given a written copy of their rights (3.2 PACE Code C).
• Girls in custody aren’t assigned to the care of a woman, which is a requirement of S31 Children and Young Persons Act 1933 (also 3.20A PACE Code C).

The force cannot show that when force or restraint is used in custody it is necessary, justified and proportionate. This is a cause of concern. There is limited, or no, recording on custody records to show when force was used, who used it and why it was necessary.

The force can’t get use of force information from its custody computer system, Athena, and instead relies on the use of the force reporting system which, in turn, relies on forms completed by officers involved in incidents. However, not all officers are completing use of force forms as required by guidance from the National Police Chiefs’ Council (NPCC). This means that not all incidents are recorded. There is little quality assurance of incidents or monitoring of use of force at a strategic or operational level, and no custody-specific external scrutiny. The scrutiny that does take place is hindered by inaccurate information and poor CCTV coverage and footage. We weren’t able to review all the cases that we wanted to because of CCTV limitations. However, of the14 cases we did assess, most techniques used were appropriate.

The quality of recording on custody records is poor and contributes to our cause of concern about the oversight of custody. While we did see some very detailed entries on custody records, important information isn’t always recorded; for example, the justification for removing detainees’ clothing, when healthcare practitioners are called, or referrals made to liaison and diversion teams.

Custody records are often a mix of standard pre-populated texts within Athena, together with the account of the actual actions carried out. This can make the record confusing and hard to understand, especially for detainee welfare checks and PACE reviews. Multiple cell visits are often recorded on detention logs all attributed to the same time, but for different detainees in different cells. This is poor practice.

Quality assurance of custody is limited. We were told that custody inspectors dip sample at least five cases each month from the suite they are responsible for. These reviews haven’t picked up the concerns or difference in practice we found, and it isn’t clear what action is taken to address concerns, or if any themes have been identified from the findings.

The force understands the public sector equality duty. Staff told us that they had received training in identifying and managing the diverse needs of detainees. The force monitors disproportionality in some custody services to assess whether outcomes for detainees are fair. There are specific actions to address any concerns. Custody staff routinely ask detainees to self-define their ethnicity to support this approach. Recent reviews have looked at identifying any disproportionality in strip searching.

The force is open to external scrutiny from its Independent Custody Visitors (ICVs), who visit each suite once a week. Custody staff are responsive in addressing any concerns or problems that the ICVs raise. Regular panel meetings consider any ongoing concerns at each suite and the ICV co-ordinator is invited to attend custody meetings.

Strategic partnerships to divert people from custody

Relationships between the force and the organisations it works with are generally good. However, limited resources make it difficult to meet the needs of children and those with mental ill health.

There is a clear priority to divert children away from custody, and overall numbers are reducing. Joint work with the youth offending teams tries to prevent and minimise re-offending to keep children out of custody and from entering the criminal justice system. There is also work with the St Giles Trust for children involved in county lines drug dealing.

Neither the force nor the local authorities it works with are signed up to the ‘Concordat on Children in Custody’, but they are working towards this. The local authorities are rarely able to help with providing other accommodation for children charged and remanded so they aren’t moved from custody as they should be.

The force works with mental health services at a strategic level to determine and meet the needs of those with mental ill health. However, this isn’t resulting in good outcomes for those with mental ill health who the police deal with on the street, or for those who need Mental Health Act assessments in custody.

Section 2. Pre-custody: first point of contact

Expected outcomes (section 2)

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

Assessment at first point of contact

Frontline officers we spoke to all had a good understanding of what makes a person vulnerable. They said factors such as mental ill health, learning or physical difficulties all contributed, as well as anyone being under the influence of alcohol or drugs or in other circumstances that made them vulnerable. Children are treated as vulnerable, although some more so than others. Officers take account of a person’s vulnerability in deciding what to do and whether to arrest when attending incidents.

Training is given to help officers recognise and understand vulnerability. They have received training sessions on, for example, domestic abuse, mental health and how children are affected by poor life experiences. But officers told us that much of the training is e-learning, which they feel isn’t the best way of learning. Information is available about support organisations that officers can seek advice from and signpost individuals to.

Information from call handlers (who take calls from members of the public) to help officers attending incidents isn’t as good as it should be. Officers told us they don’t always receive all the available information about the individuals they are dealing with, or not in time to help. They attributed this mainly to the difficulties of getting this information from the force’s computer system.

Officers have mobile devices and laptops, but they can’t always retrieve information from them because some of the technology is too old. Phone and internet signals can also be poor, especially in the more rural areas of the force. Officers often depend on their own local knowledge of people or ask their sergeants to search for information. This means that some decisions are made without good information, and this limits officers’ ability to explore whether alternatives to arrest are appropriate.

Children are only taken to custody as a last resort. Officers appropriately explore alternatives to custody. These include practical solutions such as taking children back to parents or to other family members and dealing with the child there, arranging for children to attend for a voluntary interview at a later date, and community resolutions. Where children admit the offence, they are referred to the local youth offending teams who work with the child to try and prevent further offending by, for example, arranging anger management sessions.

Sometimes the seriousness of the offence or safeguarding concerns mean officers have no choice other than to arrest the child. In all the cases we looked at where this occurred, taking the child to custody was the right decision.

Frontline officers attending incidents involving people with mental ill health have limited advice and help from mental health professionals. Officers told us that when considering detaining a person under section 136 of the Mental Health Act 1983 they contact the mental health crisis teams for advice. However, they said they often have to wait a long time to speak with a mental health professional and sometimes can’t contact anyone at all.

In the Worcester area the force and the mental health service are piloting a mental health triage car to help officers respond to incidents. However, its hours of operation are limited and we were told that there wasn’t always a mental health professional to staff it even during its hours of operation.

Officers told us that this limited help meant they couldn’t always consider alternatives, and often had no choice but to detain under section 136 for the safety of the person or others. This regularly meant long waits with the detainee for an ambulance, or at the health-based place of safety for a Mental Health Act assessment. If mental health beds aren’t available officers take detainees to hospital accident and emergency departments, where again there are long waits. This is a poor outcome for those in mental health crisis and a poor use of police officer time.

Officers don’t take people detained under section 136 to custody as a place of safety. However, where officers attend an incident because an offence has been committed, they told us they would usually arrest the individual and any suspected mental ill health would be dealt with in custody. They continue to investigate the offence unless the detainee’s mental health deteriorates, or a Mental Health Act assessment determines that the detainee needs to be transferred to a mental health facility.

Officers transport detainees to custody in police vans or police cars depending on the detainees’ behaviour and the risks posed. There are no arrangements for people with mobility problems or wheelchair users, but officers said they would adopt a practical approach and help detainees get into a police van.

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

Most custody officers are patient and respectful in their dealings with detainees. During routine interactions, however, detention officers rarely engage proactively with detainees. Most checks are conducted through spyholes, which limits opportunities for meaningful communication. While generally respectful, most interactions are because of detainee requests rather than active offers of care by detention staff. When we viewed CCTV footage, we saw a few instances where attitudes were discourteous to detainees.

Booking-in areas are mostly small. Desks are of a suitable height, but the Perspex screens introduced to reduce COVID-19 transmission sometimes distort sound and prevent clear communication. Custody officers attempt to deal with detainees one at a time but this isn’t always possible. The booking-in areas can become cramped and noisy very quickly, limiting effective communication and compromising privacy and confidentiality, especially during the risk assessment and release procedures. Detainees are offered the option of speaking with a member of staff in private, but this is after sensitive matters have already been discussed.

Signs promoting the operation of CCTV aren’t always displayed prominently for detainees to easily see. In the few cells covered by CCTV the toilets are obscured from view, but detainees aren’t routinely advised of this when taken to the cell.

In the booking-in areas detainees can see the CCTV monitors, which show activities in some of the cells and other parts of custody, such as the room where detainees are breathalysed. This is especially the case at Hereford and Worcester suites and is inappropriate. Most shower areas are situated on cell corridors and have low stable doors, which aren’t private enough.

Some custody practices are disrespectful and don’t protect the dignity of detainees. The routine removal of footwear and failure to provide replacements means some detainees walk around custody in their socks. Some remain in rip-proof clothing when they are taken from their cell for custody processes. Detainees generally have to request toilet paper and menstrual care products rather than these being offered.

Meeting diverse and individual needs

The individual and diverse needs of detainees aren’t met consistently.

None of the custody suites cater adequately for detainees with disabilities or impaired mobility. There are no adapted cells, shower or toilet facilities for use by detainees. Only one or two thicker mattresses are available to raise the height of benches if needed. Most showers and exercise yards have step access. However, most suites have a wheelchair and detainees are allowed to retain mobility aids depending on the risk assessment. We also saw custody staff try to make detainees with limited mobility more comfortable in their cells, including by providing a chair and extra pillows.

Custody staff aren’t aware of hearing loops, but most cells (except in Worcester) have coloured bands to assist those with impaired sight. Copies of PACE Code C in Braille are available in all suites and custody officers know how to access British Sign Language interpreters if needed. But copies of easy-read rights and entitlements aren’t readily available or known about, and are used rarely. Some staff we asked could describe a reasonable awareness of how they might manage the neurodivergent needs of detainees.

Women are told during booking in that they can speak with a member of staff in private. They aren’t routinely allocated a female member of staff, and on the few occasions this happened there was little meaningful interaction as a result. Women are generally asked if they need any menstrual care products when booked into custody, but after this they need to ask for them rather than staff checking whether they need them. Each suite stocks a reasonable range of menstrual care products. With the exception of Telford, where appropriate bins are provided on cell corridors, disposal arrangements rely on custody staff taking the used products away. This is unsatisfactory. Women are referred to the liaison and diversion team but aren’t always seen before they leave custody.

The provision for detainees who speak little or no English is inconsistent. Custody officers described the routine use of the telephone interpreting service during booking in, but not for other important processes, such as reviews of detention, taking biometrics, general care or welfare checks and release. This potentially limits detainee understanding of these processes. There are dual-handset telephones to aid interpreting, but they tend to be used on loudspeaker, which reduces privacy for detainees. Custody staff have a good awareness of the needs of transgender detainees and described well how they would meet their needs.

On arrival, detainees are routinely asked about religious needs. But the supply of religious items and texts to meet these needs is inconsistent throughout the suites and not all staff know about them. They are mostly stored respectfully, but some are in a poor condition and some main faiths aren’t adequately provided for. Qibla markings, indicating the direction of prayer for Muslim detainees, are clear in most cells except Worcester and Hereford.

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, as many of the concerns we raised in 2014 remain.

While most detainees are booked into custody promptly, during busy periods others can wait a long time in holding rooms, in van docks or in vehicles before their detention is authorised. Queues aren’t managed well. Staff don’t assess risks or prioritise booking in children or vulnerable adults.

When completing initial risk assessments with detainees, custody officers focus appropriately on identifying risks, vulnerability factors and welfare concerns. They interact well with detainees to complete the risk assessment and ask relevant supplementary and probing questions. There is routine cross-referencing to the Police National Computer warning markers and intelligence systems to help identify additional risks. Arresting and escorting officers aren’t always asked if they have any relevant information to contribute. There are also sometimes delays in completing risk assessments if they cannot be done when the detainee arrives because they are under the influence of drugs or alcohol or are uncooperative.

Observations of detainees are generally set at a level that is commensurate with the risks presented. However, detainees under the influence of alcohol and/or drugs and on Level 2 rousal checks (as set out by APP guidance) are often taken off these too quickly, and with poor justification for this decision recorded. Custody officers are responsible for setting detainee observation levels, but detention officers often record these reductions in observation levels, which is inappropriate. 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. Some custody records showed multiple cell checks recorded rather than individualised to the detainee, which is poor. As with rousal checks, different staff members carry out these 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. Custody records rarely include details of the briefing, or the identity of officers involved.

Officers conducting these duties frequently remain in post for long periods without any breaks, and some officers aren’t always properly focused on their duties. For example, we observed some using their mobile device and laptops when they should be vigilant in supervising detainees. Custody staff should conduct welfare checks, and carry out rousals if required, on detainees who are subject to Level 4 supervision, but this isn’t always happening. Guidance sheets are available but aren’t always used and detention logs, completed by officers conducting the Level 3 or 4 observations, aren’t attached to the detainee’s custody record. Some of the areas where Level 3 monitoring takes place aren’t themselves covered by CCTV cameras. These practices don’t follow APP guidance.

Regardless of presenting risks, most custody officers continue to routinely remove footwear and clothing with cords from detainees, and other items such as spectacles and jewellery, rather than making an individual risk assessment. There is rarely any recorded justification for this.

Rip-proof clothing continues to be used frequently, often without adequate rationale. On occasion the use of rip-proof clothing appears to be punitive or pre-emptive and as a first response rather than considering other ways of managing the risks. In many cases the use of rip-proof clothing is justified simply because the detainee hasn’t answered the risk assessment questions, rather than because of specific concerns about risks posed. This is contrary to force policy.

Detainees in rip-proof clothing are often placed on low-level observations, suggesting that their risks aren’t considered to be that significant. Even when detainees are on a constant level of observation, their clothing is often still removed. These practices are a disproportionate response to managing risk and lead to poor outcomes for detainees, particularly when force is used to remove clothing. It is our view that risks could be better managed by higher levels of observations and talking with detainees.

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 carry out their handover at the booking-in desk, while detention officers hold a separate handover in the back office, which isn’t covered by CCTV, and there is no routine sharing of information afterwards. After the handover, custody officers rarely visit the detainees in their care. Again, these practices don’t follow APP guidance.

Cell call bells are audible and generally responded to promptly on the intercom system. However, not all custody staff carry anti-ligature knives, which limits their ability to respond if they enter a cell and a detainee is using a ligature to self-harm. This is poor practice. However, the force took immediate steps to address this.

The management of cell keys is poor. There is little oversight when they are given to non-custody staff, which diminishes the control that custody staff should maintain. Non-custody staff don’t always have access to anti-ligature knives, which means they cannot respond quickly if they need to cut a ligature from a detainee.

Individual legal rights

Many detainees are booked into custody promptly. Some can wait a long time if the suite is busy and there is only one custody officer on duty.

Custody officers appropriately authorise detention when booking detainees into custody. Arresting officers provide the detailed circumstances of arrest, and give explanations of why detention is necessary (PACE Code G). Custody officers are confident in refusing detention if it doesn’t meet the necessity and proportionality criteria (PACE Code G). We saw them provide support and guidance to less experienced arresting officers so that detention decisions could be made correctly.

The force uses voluntary attendance effectively to divert people from custody. Information provided by the force shows that 4,628 individuals were dealt with as voluntary attendees in 2021 rather than arresting and taking them to custody. Many voluntary attendees are interviewed in rooms at the police stations, but some are taken into a custody suite for interview so aren’t diverted as intended.

Cases aren’t always progressed as quickly as they could be. Average detention times aren’t excessively high, but our analysis of custody records suggests some variations between suites.

Information provided by the force shows that the number of immigration detainees has decreased in the last three years. In 2021, immigration detainees spent an average of 12 hours and 10 minutes in custody after the immigration papers (IS91) were served.

Custody officers generally give good explanations to detainees about their 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.

But detainees don’t always receive their rights and entitlements in the correct way. All the custody suites have enough copies of the ‘Rights and Entitlements’ leaflet detailing detainees’ individual rights and entitlements, treatment and care while in custody. However, this leaflet isn’t always handed to detainees as required by PACE Code C paragraph 3.2. PACE Code C booklets (recent edition August 2019) are available at all of the suites, but not always proactively offered (see cause of concern).

Posters advertising the right to free legal advice displayed in languages other than English aren’t clearly displayed at any of the booking-in desks – as required by PACE Code C paragraph 6.3. However, these were ordered during our inspection.

Not all custody officers we spoke to were aware of the requirements of PACE Code C Annex M (translation of documents and records) so that detainees can receive important information about custody processes in a language they can understand. Some knew that translated documents were available on the force’s computer system, but others weren’t aware of this.

Easy-read versions of the ‘Rights and Entitlements’ aren’t often handed out in any of the custody suites. There are copies in some of the suites, but staff didn’t always know about them. We saw examples where some detainees, for example those with learning difficulties, and children, would have benefited 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 are aware of how to contact the relevant Embassies, Consulates or High Commissions for foreign nationals coming into custody if the detainee requests this.

DNA is stored in fridge freezers. These aren’t locked, which could bring the integrity of the samples into question. They are regularly collected from the suites. We saw posters in two suites explaining the Protection of Freedoms Act 2013 and the retention and destruction of DNA samples. However, we didn’t see this orally explained to detainees or the poster being brought to their attention.

Reviews of detention

Reviews of detention aren’t always carried out well or in the best interests of the detainee. Some aspects don’t meet the requirements of PACE Code C (see cause of concern).

Most reviews are carried out on time – but when they are not, the reason isn’t always noted on the custody record.

Few reviews are by telephone, which is good, But many are conducted while the detainee is asleep (sleeping reviews). We found that these weren’t always carried out in a rest period. Sometimes they were for children and vulnerable adults when consideration should have been given to face-to-face reviews in line with PACE Code C paragraph 15.3 C. Detainees are rarely informed at the earliest opportunity that a review has taken place while they were asleep, despite the fact that it is made clear on the custody record that this needs to be done. This doesn’t meet the requirement of PACE Code C paragraph 15.7.

The quality of the reviews varies. We saw detainees treated courteously and reminded of their rights and entitlements. But detention was often authorised before the detainee was given the opportunity to make any representations, contrary to PACE Code C paragraph 15.3, and often there was little discussion about their welfare.

Recording of reviews is mixed but generally 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.

Although the force has a clear bail management process to monitor suspects who are bailed or released under investigation, many cases are taking too long. We were told this is because frontline staff carry out most of the investigations – even complex fraud cases – but don’t have time to progress them due to competing demands on their time.

Our custody record analysis showed about 60 percent of cases were finalised during the first period of detention. However, detainees bailed or released under investigation (RUI) pending further enquiries wait too long for their cases to be completed. There is some management and review of investigations of suspects, but nearly half of RUI cases are over six months old.

Notices are provided to detainees when they are released under investigation outlining the possible offences they may commit if they interfere with victims or witnesses while the investigation is being carried out. We saw examples of when these were explained to detainees well and when they were not.

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 weren’t clear on the procedure for taking a complaint from a detainee while they were in custody. Some custody officers said they would send detainees who wished to complain to the front counter when released; others said they would tell them they can complain online or write in.

There are no prominently displayed posters in any custody suite or leaflets explaining to detainees how they can make a complaint while in custody. However, posters were put up at each booking-in desk by the second week of our inspection.

Few complaints are received, but we aren’t assured that detainees have the opportunity to make a complaint, or that when complaints are made they are taken, recorded and dealt with.

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 West Mercia comprise five full-time designated suites at Hereford, Kidderminster, Shrewsbury, Telford and Worcester.

General conditions throughout the five suites vary due to their age and the design of the buildings. Although cells are reasonably well maintained, cleanliness requires improvement. Some cells are superficially clean but there is debris and ingrained dirt in some corners of benches and floors. There is no regular programme of deep cleaning in place.

There is some natural light in all cells, but graffiti is evident in several cells on bench surfaces, walls and doors. Cells that have sinks installed don’t have any signs to indicate if the water is drinkable.

There are potential ligature points in most of the suites, mainly due to the design of toilets, sinks and some loose hatches. A comprehensive illustrative report detailing these, and the general condition of the suites, was provided during the inspection. The force responded positively to this, taking immediate action to remedy some of the issues highlighted.

Facilities vary throughout the suites. For example, cells at Telford and Worcester have benches that are either too high or too low to meet current guidance, cells at Kidderminster and Telford don’t have sinks. Shrewsbury doesn’t have an exercise yard or a closed visit room, but the force had finance and plans agreed to provide an exercise yard.

Daily and weekly safety maintenance checks of the physical environment, including the cells and communal areas, are completed as required by APP guidance. In two suites the weekly checks, which custody officers should do, are delegated to detention officers, which is inappropriate. Repairs aren’t always completed quickly; for example, one suite had been without hot water for over three weeks at the time of the inspection, which was poor for detainees wanting to wash or shower. Several of the suites have cells that have been out of action for several months.

The CCTV system is old and there is poor coverage in the suites and in cells. During our review of CCTV footage, we found some issues relating to the operation and accessibility of the CCTV systems (see Safety: use of force). Notices that CCTV is in operation aren’t always prominently displayed where detainees can see them and there are none in any of the cells covered by cameras.

Most custody staff have some awareness of emergency evacuation procedures and there are enough handcuffs to evacuate cells if needed. None of the staff we spoke to had taken part in a physical evacuation to make sure the procedures work in practice. On attempting a walk-through of the fire exit routes with staff in two suites, we encountered obstacles that would hinder an evacuation. The force is unable to supply details of any recent evacuation drills.

Safety: use of force

Overall, when force is used on detainees in custody it is usually proportionate to the risks or threats posed. However, information about when and how force is used is limited, and the recording of it on custody records is generally poor. West Mercia Police doesn’t know how often force is used. This is a cause of concern.

Officers who use force on detainees in custody don’t always submit individual ‘use of force’ forms as required by NPCC guidance. Some officers told us that they don’t always submit these forms when handcuffs are used on compliant detainees, or if sometimes they have difficulties with the force’s computer system. We asked for use of force forms for the incidents we looked at during our case audits and on CCTV, but in some cases not all the required forms could be provided, and in five cases no forms could be provided at all. On some of the forms we looked at the quality of the information was poor. Some use of force incidents weren’t recorded at all on custody records and sometimes the record didn’t reflect what we saw happening on the CCTV footage. This poor level of information means it isn’t possible to know how often, and what type of force is used in custody.

We reviewed 14 cases of use of force on CCTV. Limited CCTV coverage in the suites and poor quality footage restricted how many cases we could assess and what we could see. In one suite we couldn’t look at CCTV at all and in another we only had partial coverage. Not all areas of custody and not all cells have CCTV so, depending on where the incident occurs, footage may not be recorded. This made it difficult for us to assess incidents. More importantly, it means the force cannot assure itself, or show to others, that when force is used in custody it is necessary, justified and proportionate.

However, in the cases we looked at, incidents were on the whole managed well. In many, the custody officer remained in control and directed the officers using the force on the detainee. Restraint techniques were mostly deployed correctly.

We also found good examples of where officers de-escalated situations well through good communication and negotiation with the detainees. However, we also saw occasions when officers allowed themselves to be provoked by a detainee’s difficult behaviour into using inappropriate language.

We saw some cases where detainees had their clothing forcibly removed to replace it with rip-proof clothing. Officers maintained the detainee’s dignity well when removing the clothing, but it is our view that the removal wasn’t always justified and sometimes appeared punitive. The justification for the removal of clothing wasn’t always recorded. It sometimes occurred when the detainee’s risk was being managed by a high level of observation (constant watch) so rip-proof clothing wasn’t needed. The removal of clothing resulted in using force that could potentially have been avoided.

We referred three cases to the force for learning. These involved the use of rip-proof clothing and the use of inappropriate language.

There is little quality assurance of the use of force incidents in custody. There is no force policy requiring custody supervisors to carry out any reviews, and few are done.

We saw many detainees arrive without handcuffs. Those with handcuffs usually had them removed quickly. However, the reasons for the use of handcuffs aren’t always recorded and the time at which they are removed isn’t recorded.

The strip searches we reviewed were generally recorded, justified and carried out appropriately.

Some custody officers and a high proportion of detention officers aren’t up to date with their personal safety training. Refresher courses are planned and some officers are now booked on them.

Detainee care

The overall approach to caring for detainees in custody is poor and is a cause of concern.

Detainees we spoke to held mixed views about their treatment. A few told us they hadn’t been given access to the services and facilities available, sometimes even after they had made requests. Most detainees had low expectations of what they could receive but said staff were generally ‘OK’ or ‘nice’ during dealings with them.

Custody records we examined showed few offers or provision of any detainee care. Our observations also showed limited care provision in practice. While we saw some good individualised care by custody officers, this was exceptional and not the norm.

The force’s custody policy explicitly states that “a request culture shouldn’t operate within any of the custody estates”. We found a request culture to be commonplace. Detainees are generally advised during booking-in about the available facilities but aren’t reminded thereafter. Detention officers aren’t proactive in offering care, but our observations showed they usually had the time and capacity to offer and provide what was available.

There is a good range of food that is suitable for most dietary requirements, including microwaveable meals, pot noodles, porridge, cereal bars, biscuits and crisps. A good range of drinks including squash and hot chocolate is also available. For detainees who remain in custody for longer periods or for whom custody food is unsuitable, consideration is given to allowing sealed food to be brought in for them, or to purchasing alternatives. However, food and drinks aren’t always offered regularly even at recognised mealtimes. They are often only provided when the detainee asks for them.

The water from in-cell sinks isn’t drinkable, but detainees aren’t advised of this. Food preparation areas are generally clean and tidy, but some microwaves used to heat meals are dirty.

Most cells have toilets, but detainees are still generally only provided with toilet paper on request. Unwrapped rolls of toilet paper are often stored on door handles or gates, which is unsanitary. Neither Kidderminster nor Telford have in-cell sinks and arrangements for handwashing there are poor. Where in-cell sinks are present, soap or paper towels are often not available. Some showers and sinks are in a poor condition. Detainees are rarely offered or provided with an opportunity to wash or shower, including those who have been held overnight or those attending court. On the rare occasions we saw detainees have a shower or use the washing facilities, they were often expected to put their used clothing back on rather than offered replacements.

Sufficient stocks of replacement clothing including jogging bottoms, T-shirts, jumpers, underwear, socks and plimsolls are available in all suites. The provision of replacement footwear is inconsistent. While some detainees choose not to wear the plimsolls provided, many aren’t given replacements and walk around the suite or their cell in socks or barefoot.

All cells are equipped with a mattress and pillow, although some are in poor repair. Sufficient clean blankets are available and are usually provided when the detainee is taken to the cell. Additional blankets are provided on request.

All suites, with the exception of Shrewsbury, have an exercise yard where detainees can access some fresh air. Following an individualised risk assessment, detainees may be left unsupervised for a period. But even though it mostly requires no staff supervision, exercise isn’t often offered or provided. The soft footballs in the yards are well used and appreciated by the few detainees who have access to them.

Each custody suite has a range of reading material and some have a small number of books in different languages. These aren’t provided proactively and we saw very few detainees with reading materials.

A small supply of other distraction activities including colouring books/pencils, puzzles and stress balls is available in all suites. But, as with other provisions, these are rarely offered to detainees.

Safeguarding

Frontline and custody officers have a good awareness of their safeguarding responsibilities, especially for children. This is helped by training to improve officers’ understanding of vulnerabilities and any safeguarding measures needed, for example, neurodivergent conditions and the role of Liaison & Diversion (L&D) services within custody. The force’s recent work with the St Giles Trust charity involving county lines suspects has also increased the awareness and focus within custody on the potential for children to be victims as well as suspects (see section 1: Strategic partnerships to divert people from custody).

Custody officers are the ones mainly responsible for making any safeguarding referrals to youth offending teams and L&D practitioners. Arresting and investigating officers also contact regional Harm Assessment Units where there are specific concerns.

L&D practitioners in each custody suite are expected to see all children and vulnerable detainees (such as women and armed forces veterans) to assess their individual needs, make appropriate referrals or signpost them to further support and safeguarding. However, this doesn’t always happen and those detained outside of the services’ working hours aren’t always picked up at a later stage. In the cases we looked at, the custody records rarely showed any relevant information about any detainees being referred to or involved with L&D so it was difficult to see what action, if any, had been taken. Healthcare practitioners don’t routinely assess all children in custody, although a pilot scheme is currently operating in Hereford where this is expected to happen.

The welfare of girls during their time in custody isn’t sufficiently safeguarded. They aren’t assigned to the care of a woman staff member to oversee their welfare for the time they are detained, as required in section 31 of the Children and Young Persons Act 1933 (see cause of concern). The force took steps to address this during our inspection.

Support for children and vulnerable adults in custody from appropriate adults (AAs) isn’t always good enough. The force expects AAs to be requested and secured to attend custody as soon as practicable, but this doesn’t always happen. While we found some good examples of parents being contacted quickly, including at night, this didn’t always result in them attending promptly to support their child – in some cases we looked at they arrived later on the following morning or afternoon, seemingly for the time of interview.

When family members cannot attend to support the individual, the force uses the Youth Support Service (YSS) for children and either Onside or The Appropriate Adult Service (TAAS) for vulnerable adults depending on the location. These services should operate around the clock but we were told that it was difficult to arrange for AAs from these schemes to attend at weekends or at night, and that their response could be variable at other times. In the cases we looked at, and from what we saw in the suites, some detainees wait a long time before an AA arrives to support them.

The force doesn’t know how well children and vulnerable adults are supported by AAs. It receives some performance information from the providers, such as the number of requests by location, but the force doesn’t monitor any information itself to show how quickly AAs are called and how long it is before they arrive, which would allow it to assess how well detainee needs are met. The poor recording on custody records makes it difficult to collect the information required to make this assessment.

Vulnerable adults may not always get the support of an AA when they should. We found several cases where individuals presented with a range of vulnerability factors, which indicated that consideration should have been given to calling an AA but wasn’t. The force says it had identified this as an area for improvement prior to our inspection and is taking steps to improve.

Written guidance for AAs isn’t freely available or regularly given to those acting as AAs. We saw some good examples of custody officers giving detailed verbal explanations to some AAs, but this wasn’t routine practice.

Diverting children from custody is a force priority. The number of children detained in custody has decreased year-on-year since 2019.

However, there isn’t always enough attention given to keeping children in custody for the least time possible. In some of our observations and case reviews we found some good examples of children whose cases were dealt with well where bail or released under investigation (RUI) was used to move them out of custody, in some cases avoiding overnight detention. However, we also identified several cases of extended periods in detention. While these usually involved serious offences, and sometimes remands in custody pending appearance at court, it was often unclear why cases weren’t finalised more quickly or what efforts were being made by overseeing custody officers to achieve this. Information provided by the force shows the average detention lengths in 2021 were significantly longer for children compared to adults.

There are few specific arrangements to help manage and reduce the effect of the custody environment on children in custody. ‘Distraction’ items such as foam footballs, board games, puzzles and colouring materials are available and we saw good examples of them being used. Some very good care was shown to one autistic child – custody staff gave a radio to them and offered to play noughts and crosses with them to ease the child’s anxiety. However, more widely there are few specific arrangements to help most children in custody. There are few ‘easy-read’ rights and entitlement documents available and they are rarely given. There is little other reading material for children, few designated cells (except at Kidderminster) and no concerted effort to arrange time outside of their cell or with their AA.

Outcomes for children who are detained and remanded into custody are poor. Of the 36 cases where this occurred last year, 29 requests were made for appropriate alternative accommodation, but only one child was moved. In seven cases no request was made because it was deemed impracticable (because of the time of night, for example, or because they would be attending court that same day). Although we were told that they try to adhere to its principles, neither the force nor its four local authority partners are signatories to the ‘Concordat on Children in Custody’, which sets out the multi-agency roles and responsibilities for dealing with these children. The force is working with its partners to improve the situation and a draft joint protocol is in development, but outcomes for children haven’t improved and there has been little progress since our previous inspection recommendation.

The force carries out some monitoring of children entering custody. The custody inspectors review these children, with further review of some cases by the chief inspector. In one area the force is starting to look at children entering custody in the previous 24-hour period at its daily management meeting to provide greater scrutiny over the children being held.

Senior officers from the force also attend a Children and Young Persons Board every quarter alongside partner agencies. This offers some strategic oversight. However, the monitoring and scrutiny arrangements overall aren’t yet making sure that enough attention is being paid to improving outcomes for children in custody.

Governance of health care

Mitie Care and Custody Limited provide physical healthcare support to detainees and a range of forensic testing in custody through the 24/7 provision of healthcare practitioners (HCPs). The Black Country Healthcare NHS Foundation Trust, Hereford and Worcestershire NHS Trust and Midland Partnership NHS Foundation Trust also provide mental health liaison and diversion services at the five custody suites.

Partnership working between these service providers and the police is mostly good and there is good support from NHS England and NHS Improvement. Governance arrangements are generally sound, with clear reporting and monitoring of services to the force. Designated West Mercia Police senior officers provide operational oversight of health activity and contract performance. This is mostly effective but relies heavily on data provided by Mitie. There is scope for the force to better assess the actual quality of healthcare provision to detainees. For example, we were advised that complaints about healthcare, which had been reported to the police, hadn’t been forwarded to the health provider for consideration or a response.

Because of the force’s large geographical spread there is an embedded HCP based in Hereford and an HCP shared between Shrewsbury and Telford, and one shared by Kidderminster and Worcester. A clinical lead oversees the work of each team. However, the service has several vacancies and there has been significant turnover of staff which is stretching resources and affecting service resilience. Custody officers reported, and we observed, shifts when staff were under pressure. This results in clinical leads all too frequently being pulled into frontline care. However, despite this we found most detainees could access HCPs without undue waits and in line with contractual requirements – due in part to the flexibility of HCPs and clinical leads.

HCPs come mostly from a nursing or paramedic background. Induction into the role makes sure skill sets meet required standards. All HCPs have access to professional supervision and ongoing mandatory training, though wider professional development opportunities are more limited.

All treatment rooms are compliant with infection prevention and control requirements, and HCPs have access to all the necessary equipment including PPE. Treatment rooms double up as forensic sampling areas, which means cleaning processes for this purpose can tie up the facility. We had limited opportunity to observe detainee healthcare, but all HCPs indicated that examinations take place in private unless risk assessments indicate this is inappropriate.

HCPs have access to a standardised emergency bag that allows staff to respond immediately if life support is needed. Equipment is checked as part of the regular HCP duties. Custody officers and detention officers have access to an automated external defibrillator (AED) and a first aid kit. All report confidence in their training and skills to deal with an emergency.

Patient care

Staff we met are experienced, competent and valued by custody staff. We looked at clinical records, which indicated that the care and support provided is appropriate to need, and the few detainees we spoke to said this was the case. This is supported by information-sharing protocols and detainee consent for sharing information. Clinical notes are recorded on SystmOne (an electronic clinical reporting system), which allows prompt verification of any current treatments. This is extremely useful in ensuring detainees’ needs are met in custody. Clinical risks and important treatment issues are shared appropriately and concisely on the detention log.

The range of health interventions provided is good. This includes making sure opiate substitution treatment can be maintained for detainees while in custody. In addition, a set of patient group directions (PGDs) enable HCPs to administer relief for detainees experiencing acute alcohol and drug withdrawal, as well as a range of other acute presentations including for agitation and anxiety. Custody officers can provide nicotine replacement products and facilitate access to salbutamol (to relieve asthma and airway-related problems) and GTN sprays (glyceryl trinitrate to relieve the symptoms of angina), which is good. However, there is no protocol for them to provide paracetamol. This means HCPs may have to travel to attend suites purely to administer this, which isn’t the most effective use of their time given the large area covered by the HCPs, and results in detainees perhaps being left in unnecessary discomfort.

Medicine management arrangements are safe and effective, with all sites having clear processes in place. There is good storage in secure cabinets and adequate stock control. Controlled drugs are safely handled, with clear accounting measures in place and any potential discrepancies robustly followed up. Individual detainee medications are safely held within their personal property.

Substance misuse

Most support for detainees with drug and alcohol problems is channelled through the liaison and diversion team. L&D practitioners can signpost detainees to local drug and alcohol services that offer a range of support and treatment. Support workers also undertake face-to-face post-release support to help detainees to engage with bespoke community services, which includes access to harm minimisation advice. In addition, practitioners from Cranston, one of the specialist community drug and alcohol addiction services, visit suites at Worcester and Kidderminster to offer face-to-face support for detainees in custody if required.

An arrest referral support programme Is being rolled out throughout the force. This is a positive development that offers detainees who are arrested for certain ‘trigger’ offences the opportunity to access alcohol and drug rehabilitation treatment programmes to try and prevent offending and divert them from custody.

Mental health

Frontline officers receive some mental health awareness training and additional training is being developed. Custody staff receive training on mental health issues and about the role of liaison and diversion (L&D) practitioners. Custody officers’ knowledge of mental health is reasonable, and in records we looked at there were examples of them appropriately refusing detention of people with mental health needs.

Three NHS trusts provide L&D services throughout West Mercia. Governance and partnership arrangements between the trusts, commissioners and West Mercia Police are good. Operational oversight is provided at inspector level. The L&D contract arrangements are due to change imminently to be provided by a single NHS trust, which will make communication and accountability arrangements more efficient.

There is an L&D practitioner based in every suite, seven days a week between 8am and 8pm. The exception to this is in Hereford where, due to staffing challenges, the service operates between 8am and 4pm Monday to Friday only. Service managers and team leaders provide oversight and supervision and also see detainees in custody.

Custody officers can make direct referrals and the L&D teams have access to the force’s Athena computer system, enabling them to screen all detainees and identify those who may benefit from their support. Detainees can also self-refer.

Practitioners appropriately prioritise their workload based on risk and need. Staffing is stretched at times, particularly in Hereford, which can mean that not all detainees are seen while in custody. However, provision is made to see people in the community after their release should they choose to engage.

Custody staff spoke positively about the service. The L&D team is motivated and skilled, providing a range of support to vulnerable detainees both in custody and in the community. They provide support with housing, benefits and other social problems as well as linking with community mental health teams. Support workers also provide tailored support post-custody to help people engage with community services.

Custody hasn’t been used as a place of safety under section 136 in the previous 12 months. However, data provided by the force suggested that 39 detainees had been taken from custody to a hospital place of safety under section 136 between 1 January and 31 December 2021. When we looked at these individual cases it wasn’t usually clear why section 136 powers were used in this way and the information about this was very confusing.

There are delays in convening Mental Health Act assessments in custody. We found four cases where detainees had spent around 48 hours in custody, which is unacceptable. Feedback received from various agencies suggests that there is a problem with the availability of doctors, particularly overnight. We also saw delays in trying to get a suitable hospital bed in some cases.

Community demand for health-based section136 facilities is significant, with 651 cases reported over the previous 12 months. Frontline officers feel that access to mental health support and advice provided by crisis teams is variable and sometimes they couldn’t get a response due to staffing problems in the crisis teams.

There is limited street triage provision, which is only available in Worcestershire three days a week. The service providers are aware of the difficulties in meeting the needs of those with mental ill health and they are working jointly with the force to better understand the problems and provide solutions. Regular meetings take place to review section 136 data and resolve issues.

There is positive collaboration between the force and the organisations they work with. For example, there is a high-intensity service user group that addresses the support requirements of those individuals in regular contact with emergency services.

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 use initial risk assessments and behaviour while held in custody to make sure any risks identified are addressed or mitigated before detainees are released. Where concerns are identified, custody officers refer to the healthcare practitioner or liaison and diversion staff to conduct a ‘fitness to release assessment’ to make sure that detainees’ needs are assessed and met where possible before release. Where necessary, other relevant agencies are also involved to support the release. However, some custody records don’t include enough detail – for example, of how a detainee is getting home after release.

Detainees who don’t have the means to get home safely can make telephone calls to arrange transport. They can also access bus tickets (only available at Telford and Shrewsbury for local buses) and travel warrants for trains. We were told that police officers frequently take children and vulnerable adults home when it isn’t possible to release them into the care of a responsible adult, and we observed this happening.

Leaflets containing information about both national and local support agencies are available and are given to all detainees on release, but not to those transferring to court or prison. However, this leaflet is only available in English.

A few custody officers are aware of the enhanced safeguarding arrangements for those arrested under suspicion of committing serious sexual offences. Most custody officers are unaware that a specialist support leaflet is available to give to detainees in these cases.

Detention officers complete electronic person escort records (ePERs) and book transport for detainees who are attending court or have been recalled to prison. Custody officers don’t always check the content of these records or sign them off before a detainee leaves the suite. A check of ePERs we conducted revealed several omissions in the documents.

Most custody officers don’t engage or complete any pre-release risk assessment with detainees transferring to court or prison, which means that identified risks may not be addressed or mitigated before transfer.

Courts

Working practices between the force and HMCTS ensure that once detainees are remanded, they are generally presented before the first available court. This is an improvement since our last inspection and means that most are held for no longer than necessary.

Detainees remanded for court are generally collected promptly in the morning but there are occasional delays when transport by the escort contractor isn’t available. This situation is being monitored by the force. 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 and minimises time in police custody.

A video link facility is available in the custody suites to hear cases virtually if necessary. This avoids unnecessary travel to court if a detainee has a disability or is known to have, or suspected of having, COVID-19. During the inspection it was used with good effect for a detainee confirmed as COVID-19 positive. He was dealt with and remanded by the virtual court and transferred very quickly to prison, meaning he spent the minimum time in custody and avoided unnecessary travel which was a good outcome for him.

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

Causes of concern and recommendations (section 6)

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 Mohyiuddin: HMI Constabulary and Fire & Rescue Services inspection officer
• Marc Callaghan: HMI Constabulary and Fire & Rescue Services inspection officer
• Ian Smith: HMI Constabulary and Fire & Rescue Services inspection officer
• Kellie Reeve: HMI Prisons team leader
• Fiona Shearlaw: HMI Prisons inspector
• Martin Kettle: HMI Prisons inspector
• Steve Eley: HMI Prisons health & social care inspector
• Mathew Tedstone: CQC inspector
• Joe Simmonds: HMI Prisons researcher
• Helen Ranns: HMI Prisons researcher

Fact page

Note: Data supplied by the force.

Force

West Mercia

Chief constable

Phillippa Mills

Police and crime commissioner

John Campion

Geographical area

Herefordshire, Worcestershire, Shropshire, Telford & Wrekin

Date of last police custody inspection

October 2014

Custody suites

• Hereford
• Worcester
• Kidderminster
• Telford
• Shrewsbury

Total of 81 cells

Annual custody throughput

13,145 – calendar year 2021

Custody staffing

• 1 chief inspector
• 3 custody inspectors
• 47 custody sergeants
• 59 detention officers (contracted via Bidvest Noonan)
• 22 healthcare professionals (HCPs, including clinical leads and seniors shared with Warwickshire)

Health service provider

Mitie Care and Custody

Back to publication

Report on an unannounced inspection visit to police custody suites in West Mercia