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Progress on recommendations
64. As noted previously in this report, we have published ten joint custody inspection reports with our colleagues from HIS, as well as two progress reports. This resulted in 45 recommendations and 33 areas for improvement being made for Police Scotland and 104 recommendations for NHS boards. In addition, HIS made 11 areas for improvement for NHS boards, and outlined 32 examples of good practice where these have been identified during inspections.
65. Details on the dates and locations of these inspections can be found at appendix A. The number of recommendations made for Police Scotland regarding each custody centre, is outlined at appendix B. Recommendations for NHS boards are at appendix C.
66. When considering the data outlined in the appendices, it should be noted that for the purposes of reporting on progress, we have separated the recommendations by those made to Police Scotland and those directed to NHS boards as the lead organisation. However, we recognise that in practice the organisations have joint responsibility for some recommendations.
67. In terms of tracking recommendations, we request an action plan from Police Scotland approximately three months following publication of an inspection report. Thereafter, Police Scotland complete an evidence submission form for each recommendation, and our inspectors review these for consideration of closure. Depending on the nature of the recommendation it can take a varying degree of work and time by Police Scotland to achieve its closure.
68. We do not track areas for improvement made for Police Scotland in the same way as our recommendations as these tend to focus on local custody centre issues such as repairs or improvements in localised practice as opposed to the more thematic nature of our recommendations. That said, Police Scotland can provide updates on progress against these at any time, and we can also explore progress during future onsite inspections.
69. HIS adopts a risk based, evidence informed approach to monitoring progress against inspection recommendations. Following publication of a custody inspection report, the NHS board and HSCP are required to submit a structured action plan setting out how each recommendation will be addressed. The action plan is reviewed, alongside supporting evidence where requested, and is subject to internal risk assessment to determine the level of assurance and any remaining risk. Formal feedback is then provided to the NHS board outlining our assessment on progress and identifying where further action is required.
70. The assessment considers if sufficient progress has been made, whether work is ongoing, or whether the recommendation is no longer applicable considering changing circumstances. Where risks remain, or progress is incomplete, this is clearly articulated and followed up through subsequent inspection activity, targeted engagement, or follow-up work to ensure that scrutiny is proportionate, focused and aligned to areas of highest risk to the safety and quality of care.
71. The following sections of this report provide details of our findings from the activities undertaken during our recommendations review. It considers progress made against existing recommendations, the extent to which they have impacted on operational practice, and where more needs to be done to achieve positive outcomes.
Custody operating model
72. The current police custody operating model is based upon the pre-Police Scotland legacy custody estate and infrastructure operated by staff comprised of police officers, civilian support staff and partners. Staffing resource is not informed by a bespoke custody demand analysis but is instead broadly determined by the number of cells at a custody centre, the number of detainees ordinarily detained, and the minimum ratio of one member of staff to ten cells that was introduced for management purposes.
73. This arguably outdated ratio, commonly referred to as the operating base level (OBL), was established through a relatively arbitrary estimation of staff capacity, rather than being founded on a quantifiable examination of operational risk and delivery. Since the inception of Police Scotland in 2013 there have been a number of custody centre closures which have, in the main, been implemented to achieve greater efficiency across the national estate.
74. The operating model is widely viewed by staff as unsafe and unsustainable as staff numbers can, at times, fall below the OBL. Until recently, the model was heavily supported by staff overtime, which of course comes at a cost. A reduction in overtime, following budgetary pressures, has exacerbated the issue as the current operating model makes it difficult to deliver services without overtime.
75. Some staff members highlighted the role of the team leader in relation to staffing levels. Whilst team leaders are supervisors and are responsible for care and welfare decision making, they are counted as a working staff member. Some agree with this approach, however others suggest this enables lower than acceptable staffing levels. Staff also described how resources often seemed to be in the wrong place at the wrong time due to a lack of effective staff roster management in some areas.
76. In the more populated parts of the country, weekend cell capacity was widely described as critical, with some detainees being transferred long distances between centres. The closure of Kirkcaldy, Coatbridge and Kilmarnock custody centres to address staffing pressures can result in longer transfers and extended queues at receiving centres. While there may be sufficient cell capacity nationally, at critical times, there is limited resilience in high volume areas.
77. Our review, and previous custody inspections, have highlighted that the operating model is not suitable for the existing estate, the current level of demand, and available staff resource.
78. The SLT for custody have identified the development of a new operating model as a top priority, noting that the current model is not fit for purpose and is sustained largely through goodwill and extensive staff movement across the estate. Police Scotland has engaged a firm of third-party analysts to explore the existing operating model in consideration of the issues identified regarding the custody estate, staff resource and demand levels to produce a model capable of supporting positive change and development. The outcome of this work is not yet clear.
79. The issues have been incorporated into the CJSD custody transformation programme for ongoing attention by the project team.
People strategy and workforce planning
80. We found that Police Scotland does not have a clearly defined people strategy for custody. Workforce arrangements lack resilience, with non-voluntary deployments to other centres, high staff absence, limited wellbeing focus, and insufficient training and development contributing to poor morale.
81. Some senior officers acknowledged that regular changes in senior personnel and second line managers within the division has impacted on operational certainty and continuity for staff. Moreover, they recognise that staffing pressures, which necessitate the movement of staff to cover shortfalls or absences at other centres, has had a demoralising effect.
82. A lack of resilience in the staffing model means that unpaid breaks are rarely taken, especially at busier times. The absence of rest breaks can potentially lead to errors, increased stress and further absence.
83. An additional factor affecting morale is the number of staff on restricted duties within custody, which inevitably places increased demand on other staff. This was acknowledged by senior officers who are working to address the issue.
84. The SLT highlighted that work is in place to improve staff morale, including development of the trauma response framework, which sets out support for staff in the event of an adverse incident. It was acknowledged that this work needs to move at pace, requires staff buy in, and must be delivered sensitively.
85. A new resource deployment unit (RDU) has recently been created for the division to better manage resources. While it is at an early stage, staff feel that the impact of this is yet to be realised, though they remain hopeful that as RDU staff become more familiar with local staffing structures and demands, they will begin to see improvement.
86. A national custody coordinator role is also being proposed to better manage demand and control inflow to custody centres. This would provide options to direct officers escorting detainees to centres with available capacity, for example travelling further to a centre with no waiting time rather than attending a closer centre that is experiencing long queues.
87. We have previously made recommendations regarding staffing levels following the joint inspections in Greater Glasgow, and Argyll and West Dunbartonshire. We recognise that this is a significant issue that will take time to resolve and will feature heavily in custody transformation plans. However, more needs to be done to build resilience in the staff complement, reduce pressure points where staff are increasingly stretched, and to restore the strong relationships that the division has maintained with staff over an extended period.
Staff training
88. Effective training and the professionalisation of the custody role were widely seen as key to consolidating improvement and supporting longer-term change for CJSD. At present, basic custody training is the same for all practitioners. It is considered by staff to be adequate overall, however, many feel it lacks situational relevance and does not reflect the realities of day-to-day practice.
89. Once staff have completed the basic five-day custody course there is little further training. CJSD recently introduced refresher training, however many staff members felt that this offered little more than basic training.
90. As supervisors, sergeants and team leaders attend a first-line managers’ course. This was previously a two-week college course, however it is now delivered as three half-days online. Supervisors stated that the course has become overly condensed and diluted, and while some aspects are valuable, it does not fully meet the needs of the supervisory role.
91. Custody sergeants reported that there is no specific training for the duty officer role, and they generally learn on the job from peers. This approach relies heavily on peers having a sound understanding of operational delivery procedures, and a high level of competence. It is therefore prone to inconsistency across the estate. Similarly, there is no specific training for the team leader role, which can result in variability in approach and performance. There was an acknowledgment by custody leaders that training currently falls short of what would be desired, with a pressing need for improvement, including through a more scenario-based syllabus.
92. We found broad acceptance that there is a need for additional training on the Criminal Justice (Scotland) Act 2016, to assist local policing officers to fully understand essential custody requirements. Despite previous efforts, there continues to be a mixed understanding of the implications of the legislation on custody practice.
93. It will be necessary therefore for staff training and development to feature strongly in custody transformation plans.
ICT systems
94. Many of the staff we engaged with described the NCS as straightforward and functional, however regarded it as outdated and unintuitive. Staff described the system as time consuming to navigate and disjointed, leading to unnecessary delays, which could encourage the use of shortcuts. They felt that an improved system should include more mandatory fields and pop-up boxes to prompt users to understand what content is required and where.
95. In our previous custody inspection reports we have highlighted significant gaps in the use of NCS, which has made it difficult for inspectors to assess the extent to which standard custody processes are being completed correctly. Custody staff stated that considerable time could be saved by improving the integration of the various platforms to avoid repetition, and we have made a recommendation to that effect. We have previously identified significant inefficiencies arising from poor integration between police IT systems, resulting in repeated manual data entry across multiple platforms, which increases the risk of error.
96. Other ICT related issues have also been raised by custody staff. Several years ago, CJSD issued electronic tablets to custody centres so that interactions between staff and detainees could be recorded contemporaneously. This was intended to address a previous recommendation, made following a joint custody inspection, whereby gaps and delays were identified in the recording of detainee observations within their cell.
97. The ability to record on the devices was intended to improve accuracy, efficiency and provide increased confidence in the practice. However, the tablets were underused for a range of reasons. Some staff stated that the software interface lacked useful functionality. Others found them difficult to use due to wi-fi problems in some centres. More recently, they were considered to pose a potential risk to the health and safety of staff and, as a result, all tablets were withdrawn. As far as we can ascertain, the situation remains unresolved.
98. Senior officers have recognised the limitations of existing custody ICT systems and stated that they are taking steps to explore new technological solutions. However, progress is at an early stage, with reliance on short term fixes and no fully developed digital solution yet in place to deliver meaningful improvement. Cost will undoubtedly be a factor as a result of funding challenges.
Review of NCS records
99. In order to assess progress on the aforenoted recording issues, as well as other operational practices, we undertook an analysis of custody records on NCS as part of this review.
100. We examined a proportionate sample of custody records from those recorded across all custody centres during the period between 19 and 25 January 2026. There were 1,797 records created in that period and we sampled 154, which equated to approximately 8.5%. The sample was selected to be broadly representative of the proportions of men, women and children who were held in custody at the time.
101. The review of NCS records provided valuable information on several aspects of custody centre operations, including risk assessment and observation levels within custody, and compliance with Police Scotland’s Care and Welfare of Persons in Police Custody SOP.
102. We found issues that were consistent with our findings from previous joint inspections of custody, many of which are the subject of existing recommendations. However, we also found examples of improved practice.
103. Children in police custody has been recognised by the National Police Care Network as an area in which many elements of the Target Operating Model (TOM) Future State[3] required further implementation. A broader multi-agency programme of work is being led by the Children and Young People’s Centre for Justice to support the implementation of the Children (Care and Justice) (Scotland) Act 2024 with a view to reducing the number of children in custody. Joint inspection activity by HMICS and HIS has repeatedly highlighted concerns regarding the detention of children. These include instances of children being held in custody for prolonged periods, for what inspectors considered to be relatively minor offences, and without sufficient management oversight or a clear rationale being recorded for custody decisions.
104. Although the overall number of children entering custody remains relatively low, inspection findings indicate that when children are detained, variability in practice presents heightened risks to their rights, safety and wellbeing. Strengthening the healthcare response, workforce capability and oversight of the care children in custody receive is essential to ensuring compliance with a rights‑based approach and the delivery of trauma‑informed, child‑centred care.
105. We reviewed 25 records for children and young people within our sample and found that the majority, 20 of 25, had been subject to oversight by a custody review inspector. While we would expect to see all cases of children in detention being overseen by a custody inspector, this marks an improvement.
106. However, there were two instances where a child was held in custody for an extended period without a clear rationale being recorded on the system. Again, while this is a relatively small number and reflects improvement, we continue to see inconsistency in the oversight and management of children across the estate.
107. We also noted instances of adults being held in custody long after a decision was made to release, an issue raised in previous inspections. In one case, a decision was made to release an individual soon after their arrival, but the detainee was held for a further 25 hours. It is essential in such cases that a clear rationale is recorded to explain and justify the extension.
108. We have consistently noted a practice where detainees are assessed as high risk at the booking-in stage, but managed at a lower level, without clear mitigation of risk being applied. Of 88 records assessed as high risk, we noted that a third of these were managed at a lower level with no clear rationale recorded to explain the circumstances. There continues to be a stubborn disconnect between high-risk assessments and the risk management response.
109. In accordance with standard operating procedures, detainees must be visited at least hourly by custody staff, and for those deemed to be of higher risk, visits can be at 30 or 15 minute intervals. We found that observation checks had been recorded in 135 of 154 records from our sample. However, many of these had been recorded up to ten minutes late. We found 10 records with checks that were late by more than ten minutes, the longest delay being 35 minutes. Many detainees are vulnerable and timely visits are important to ensure their care and welfare. We recognise that this remains a challenge for custody, particularly in consideration of the aforementioned staffing challenges, however given what has been said in this report about better use of ICT systems, and improvements to the operating model, more needs to be done at pace to resolve the issue.
110. Forty-seven records indicated that a detainee had been strip searched. All but two were appropriately authorised by a custody sergeant. In ten records, the rationale to justify a strip search was very limited. One had no rationale, and in seven there was no search page. We have highlighted the necessity for improved practice in recording a suitable rationale for strip searches in previous recommendations.
111. There were three records related to ancillary centres in our sample that lacked an adequate level of remote supervisory oversight. This subject was raised in our joint inspection of custody centres in the Highland and Islands division and remains an issue for ongoing attention from the custody division.
112. We found, in the majority of cases, that the recording of handovers between supervisors was often generic and lacked specific details relevant to individual detainees. This issue has been raised in previous inspection reports as a potential risk and is subject to a current recommendation.
113. As outlined previously in this report, the quality assurance and performance function is, in part, undertaken through a monthly audit based on the dip-sampling of records. While this is a welcome introduction, it is evident that further progress will be needed to continue to embed improvements relevant to the recommendations outlined in this section of our report.
[3] The Target Operating Model (TOM) Future State describes the nationally agreed vision for police custody healthcare in Scotland, setting out the improvements required to deliver consistent, equitable, person-centred and trauma-informed healthcare across all custody settings.