A new report traces some of the problems at Santa Clara County’s jails to a lack of staffing, training, funding and a deeply divided work culture.

Sheriff Laurie Smith asked for the review by U.S. Department of Justice affiliate National Institute of Corrections after a mentally ill inmate was found fatally beaten in his cell last August. The resulting 36-page analysis—available here—concluded that while the jail isn’t broken, it needs a "serious tuneup."

“We suspect that the jail has not had the organizational care and feeding that it needed,” the report’s authors, retired peace officers Gary Raney and Ron Freeman, wrote. “A lack of adequate resources, combined with more demand, makes many issues somewhat predictable in hindsight.”

The authors spoke to randomly chosen 77 line-level jail staffers, six Sheriff’s Office administrators and close to 30 jail stakeholders—that is, people including chaplains and inmate advocates who work in the jails, but not directly for the county.

The report’s authors state that they saw no evidence of systemic use of excessive force. But while the guards have “good hearts,” they said, they unnecessarily escalate tensions by failing to treat inmates as people.

“We saw very few instances where inmates were greeted cordially by staff with calming words like, ‘How are you today?’ or ‘Good afternoon,’” the report states. “The majority of staff-inmate interactions began with tension and a directive, rather than a request.”

The approach makes sense for violent criminals, the report explains, but creates avoidable resistance from other inmates.

“One employee said, with some disgust, that, ‘They want us to act like a counselor,’” the report states. “Well, yes we do when necessary. Whether it is in the jail or on the street, contemporary law enforcement officers must have a range of skills and approach situations as problems solvers and helpers. Jail staff can no longer just be ‘guards.’”

That us-against-them mentality is ingrained in the culture of the jails, the report states. It also extends to Sheriff’s Office staff. Since the county placed the Department of Corrections under Sheriff Laurie Smith’s purview as a cost-saving measure in 2010, the correctional side has felt that she has favored enforcement deputies over jail staff.

The report also found fault with the lax promotion model, which led to inexperienced people moving up in the ranks and creating a suspicions of favoritism. Meanwhile, jail employees repeatedly said that morale has hit an all time low. Most of the deputies asked to rate job satisfaction on a scale of one to 10 answered, “two.”

The Sheriff’s Office needs to train correctional staff in its new use-of-force policy, the report advises. It also needs to come up with an effective promotional process. Sheriff Smith should include her staff in the decision-making process, so they don’t feel uninformed about why certain changes are made.

The jail guards’ union, the Correctional Peace Officers’ Association, said the report echoed many of the same concerns its members have raised for years. The union brought up many of the same issues to the “blue ribbon” jails reform commission formed last year in reaction to Tyree’s death.

“The report’s focus on unsafe staffing levels, insufficient training and weak leadership and supervision is in line with our recommendations to the Blue Ribbon Commission,” acting union president Julio Alvarez wrote in an email. “This is why we need a seat at the table in determining policy, which we have been denied for too long.”

Sheriff Smith said the report validates the work ethic of her jail deputies and underscores the importance of the reforms underway.