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Torbay & Devon Safeguarding Adults Partnership Annual Report 2020/21

Chair's foreword

Paul Northcott – Chair of the Torbay and Devon Safeguarding Adults Partnership (TDSAP)

Paul Northcott


The merger of both the Torbay and Devon Safeguarding Adults Boards into the TDSAP has presented a unique opportunity to strengthen the partnership and build on the previous successes that have been achieved in both areas.

I would like to thank the two previous chairs and the senior managers for all of their commitment and vision in progressing the merger.

Joint working opportunities have enabled us to progress the work that has been detailed in this report whilst also enabling us to plan for the challenges that we will encounter in the future.

The new priorities for the partnership will ensure that we focus on those areas that will improve safeguarding practice and ensure that we are effectively working together to deliver services that meet the needs of vulnerable individuals and the wider community.

Community and service user engagement continues to be developed and is seen by the partnership as essential in building on the progress that has been achieved and informing future practice.

Julie Foster – former chair of the Torbay Safeguarding Adults Board

Julie Foster

Like many other organisations across the world, Torbay Safeguarding Adults Board has had to adjust the way it operates during the current pandemic. Meetings have had to be convened virtually and some of our activities suspended temporarily whilst pressing priorities to safeguard a much wider population were actioned.

The responsiveness and flexibility of our partners has been fantastic and, despite the need to work differently, safeguarding adults’ activity has continued relentlessly and those at risk from harm have been protected.

Steps have been taken to publish the help available in cases of both domestic and financial abuse – issues that caused a particular concern during lockdown.

We have also taken steps to monitor the impact of very busy health and care systems on hospital discharge and care at home to ensure adults at risk do not fall through gaps.

It is to the credit of our senior managers that the plans to develop a new Safeguarding Adults Partnership between Devon and Torbay have reached fruition during the past year.

Torbay is keen to maintain its own identity and has its own particular opportunities and threats, but it makes sense to build on our close links with Devon to provide a consistent approach across the area and to reduce the duplication and resource requirements of two separate Boards

Siân Walker – former chair of the Devon Safeguarding Adults Partnership

Sian Walker

The pandemic had a massive impact on all of us, especially on vulnerable people living in Devon’s communities.

Whilst, like others, we had to adjust the way we worked, the Devon Safeguarding Adults Board continued to function well, adapting to more regular updates from statutory partners from the Council, police, NHS and the voluntary and community sector. This provided information and data which enabled us to take immediate action where appropriate.

The Board continued to function with virtual meetings but work behind the scenes changed as board support staff were deployed to front line services, importantly to resource services to support effective safeguarding.  We maintained a good overview and I felt assured that safeguarding remained a top priority by all partners.

I worked alongside other safeguarding chairs in the south-west so we could all learn from one another, adapt and be agile to these new circumstances.

I ensured that we maintained our ability to respond well to the very many circumstances in which people found themselves, both citizens and professionals across the partnership as we supported them all in their COVID-19 response.

Plans were progressed during this time to merge the Devon and Torbay Safeguarding Adults Boards, something which I fully supported in the knowledge that our partners worked across both Council areas, and it enabled a more dynamic and efficient way of working.

I was delighted, after chairing the Devon Safeguarding Partnership for 5 years, to leave it in a far healthier position. I am grateful for the opportunity I had to work across our county and delighted to hand over to Paul Northcott with the newly merged Partnership Board.

Our role and purpose

The TDSAP is the collective name for the partners that work with the Board to safeguard adults across Torbay and Devon.

The TDSAP was founded in the final quarter of 2010/21 by Devon County Council and Torbay and South Devon NHS Foundation Trust as a requirement of the Care Act 2014. It provides strategic leadership for adult safeguarding across Torbay and Devon.

Prior to the creation of the TDSAP, there were two separate boards operating in Torbay and Devon; the Devon Safeguarding Adults Partnership and the Torbay Safeguarding Adults Board.

The TDSAP is completely independent, with an independent chair.

The core objective of the Partnership, set out in section 43(2) of the Care Act 2014, is to help and protect adults in its area in cases where an adult has care and support needs and they are experiencing, or at risk of, abuse or neglect and as a result of those care and support needs, they are unable to protect themselves from either the risk of or the experience of abuse or neglect.

The TDSAP acts as the key mechanism for agreeing on how agencies work together to safeguard and promote the safety and wellbeing of adults at risk and/or in vulnerable situations. It does this by coordinating what each of the TDSAP members does and making sure that they do it effectively.

The TDSAP multi-agency partnership aims to promote awareness and understanding of abuse and neglect among service users, carers, professionals, care providers and the wider community. It works to generate community interest and engagement in safeguarding to make sure that ‘safeguarding is everyone’s business’.

The TDSAP also commissions Safeguarding Adults Reviews for people who have experienced poor safeguarding outcomes, to ensure that lessons are learned for the future.

Our structure

The TDSAP established the below structure to undertake the work on behalf of the Partnership. These meetings are supported by the Partnership Business Manager and Partnership Coordinator. Each sub-group has a regularly reviewed terms of reference.

When required, task and finish groups are established to deliver key elements of work commissioned by and reported to the Partnership. These task and finish groups comprise of representatives nominated by Partnership members who have sufficient knowledge and skills to contribute to the required task.

The TDSAP organisational structure

Our partnership members

The TDSAP has representatives from the following organisations:

  • Torbay & South Devon NHS Foundation Trust
  • Northern Devon Healthcare NHS Trust
  • Royal Devon & Exeter NHS Trust
  • University Hospitals Plymouth NHS Trust
  • NHS Devon Clinical Commissioning Group
  • NHS England/Improvement
  • Torbay Council
  • Devon County Council
  • East Devon District Council
  • Devon Partnership Trust
  • Livewell Southwest
  • South Western Ambulance Service Foundation Trust
  • Devon & Cornwall Police
  • HM Prison & Probation Service
  • Devon & Somerset Fire & Rescue Service
  • Care Quality Commission
  • Living Options
  • Healthwatch
  • Trading Standards
  • Housing
  • The Department for Work and Pensions

Safeguarding Adults Reviews

The TDSAP must arrange a Safeguarding Adults Review (SAR) when an adult in its area dies as a result of abuse or neglect, whether known or suspected, and there is a concern that partner agencies could have worked more effectively to protect the adult.

The TDSAP must also arrange a SAR if an adult in its area has not died, but the SAB knows or suspects that the adult has experienced serious abuse or neglect. Boards may also arrange for a SAR in any other situations involving an adult in its area with needs for care and support.

Consistent SAR themes from 2020/21 referrals include:

  • mental health
  • suicide
  • self-neglect
  • COVID-19 lockdown impact

The SAR Core Group continues to meet quarterly and has done so throughout the COVID-19 pandemic. The Core Group is attended by representatives from partner organisations including CCG, NHS, local authorities and the police.

SAR activity during 2020/21

There have been 24 SAR referrals during the period of 2020-2021 of which:

  • 10 were received by Devon Safeguarding Adults Partnership
  • 3 were received by Torbay Safeguarding Adults Board
  • 11 were received by the TDSAP

There have been four SAR learning events across Torbay and Devon.

In 2020/21 the Devon Safeguarding Adults Partnership published one SAR – ‘SAR Ben’.

Summary of SAR Ben

Ben was 57 years old when he died. He was reported missing on 3 November 2018. His body was found off the coast of Devon on 5 November 2018. He had not been seen for several days before this.

Ben had Huntington’s Disease. Huntington’s Disease is a relentlessly progressive neurodegenerative disorder which, for Ben, resulted in complex care needs. The difficulties Ben experienced as a result of the impact on his frontal lobe resulting from his Huntington’s Disease, impacted on his ability to cope with daily life.

Given Ben’s complex needs and associated risks, his care and support needed to be considered in a multi-agency and multi-disciplinary way.

At the time of his death, Ben was being supported by several agencies. Ben’s family held a view that a different approach to working alongside Ben was needed.

Learning point: Experience, skills and confidence of staff working with Huntington’s Disease

The experience, skills and confidence of staff working with someone who has a complex long-term condition plays a big part in the success of such support. In Ben’s case more could have been done to utilise the expertise of both services and family members with relevant experience.

Ben was well known to the Huntington’s Disease regional advisor who could have been contacted to assist with care planning. However, this did not happen. Staff should have proactively engaged the support of condition-specific specialist services in their assessment and planning of care.

There should have been greater focus on Ben’s strengths and personal goals.

Learning point: Mental health commissioning arrangements

The review highlights the disjointed nature of Devon’s mental health commissioning arrangements for people with a diagnosis of Huntington’s Disease.

In Devon, there are several commissioned services within the community, both for long-term conditions and mental health, which may be able to support a person’s mental health needs. The suitability of the service would be dependent on a person’s presentation, stage and primary need and diagnosis.

In Ben’s case, services available appeared to be based on diagnosis rather than need. As the Community Mental Health service in Devon is not commissioned to provide a single identified ‘neuropsychiatric care’ service, Ben did not receive community mental health support. There does not appear to have been consideration of alternative services to provide support.

There is an apparent lack of awareness across the health and care system regarding the range of services available for people with a diagnosis of Huntington’s Disease, the criteria, the limitations of the services, and how these services can be accessed.

Learning point: Risk assessment and risk management

The perception that multi-agency risk management can’t occur unless under the auspices of undertaking a safeguarding enquiry needs addressing. In Ben’s case, there was a significant delay in getting a multi-disciplinary team response to risk.

There was a difference of opinion across organisations around what are acceptable levels of risk for Ben. There needs to be more regular use of multi-disciplinary risk management meetings with clear outcomes and actions attributed to all agencies.

Multi-agency risk assessments must be of a sufficiently high standard and include feedback from key agencies and significant others in the person’s life.

More information is available on our website about TDSAP SARs, including copies of previously published SARs as well as guidance on how to raise a concern.

TDSAP sub-groups

Community Reference Group

The newly formed Joint TDSAP Community Reference Group (CRG) includes people recruited from local voluntary, community and social enterprise (VCSE) and people with lived experience of the safeguarding process, across the TDSAP area.

The CRG has grown from strength to strength undertaking co-production, consultation and engagement work. Methods to gather intelligence have included focused task and finish groups, online and telephone surveys and varied user-led dialogue.

The CRG has provided new ways for people who have been through safeguarding processes to input directly into the work of the partnership.

The CRG provides feedback on key priorities for future work, is raising awareness of safeguarding with the adult population and two-way communication channels with representatives within and across the VCSE.

In 2021 the CRG brought the voice of the service user into the Annual Partnership Development Day and ensured that the voice of the people we support, remains central to the planning of future partnership priorities.

Learning and Improvement Sub-Group

The Learning and Improvement Sub-Group has continued to undertake and complete key areas of work, despite meeting less frequently than usual in 2020/21 due to partner agencies responding to health and social priorities related to the COVID-19 pandemic.

These areas of work include the Partnership reviewing, retendering and awarding a contract to provide a comprehensive range of safeguarding adults and mental capacity act training. The majority of the training during the year was delivered virtually due to the COVID-19 pandemic.

The safeguarding adults training strategy has remained a key focus following its approval last year. Assurance was sought from partners regarding individual progress in order to develop a partnership-wide implementation plan.

Mental Capacity Act Sub-Group

Over the previous 12-month period the work of the Mental Capacity Act Sub-Group experienced some disruption as a consequence of the COVID-19 pandemic response.

Although some of the sub-group meetings were stood down, to allow partners to concentrate on their COVID-19 pandemic responses, the existing work plan was regularly reviewed and updated once the group was in a position to reconvene.

There is renewed energy amongst our partners for collaborative working wherever possible and a recognition that there continues to be an ongoing need to increase legal literacy across operational staff groups to protect the wellbeing and rights of people we support across Torbay and Devon.

The priority work will continue to be focused on:

  • increasing understanding and application of Legal Literacy across partner organisations
  • the Liberty Protection Safeguards which are expected to come into force in 2022
  • the use of lawful restrictive measures
  • the Mental Capacity Act 2005 learning outcomes from SARs

The group continues to work in tandem with the Learning and Improvement Sub-Group and the interaction between these two sub-groups is regularly reviewed to ensure this organisational arrangement is fit for purpose to help deliver the strategic priorities of the partnership.

Operational Delivery Group

The Operational Delivery Group (ODG) oversees all of the above sub-groups and reports directly to the Partnership Board.

In 2021/21, following a review of the Safeguarding Insight Data, the ODG established four task and finish groups to review the data and suggest areas for improvements. The four groups focused on:

  • care homes
  • types of abuse
  • blue light services
  • health referrals

The Partnership has been supporting the local authorities to help inform a national picture in relation to the COVID-19 pandemic. The results of which are shared back to local authorities and our Partnership to inform future learning opportunities, via an Insights Data Report.

The ODG continues to review and consider developing areas of adult safeguarding to ensure that partners are well informed to respond to emerging themes and trends.

TDSAP priorities 2020/21

Prior to the establishment of the TDSAP in December 2020, the Torbay Safeguarding Adults Board and the Devon Safeguarding Adults Partnership had separate strategic priorities held within their own business plans.

Former Torbay Safeguarding Adults Board (TSAB)

The TSAB Business Plan was for the period 2018-2021 and its priorities included:

  • embedding making safeguarding personal
  • learning from Safeguarding Adults Reviews
  • the interface between safeguarding adults at risk and domestic abuse/sexual violence
  • preventative and creative solutions
  • the Mental Capacity Act
  • market shaping and commissioning

Former Devon Safeguarding Adults Partnership (DSAP)

The DSAP Business Plan for 2020-2021 included the below priorities:

  • Safeguarding within the COVID-19 pandemic:
    • To work in partnership to ensure continuity of safeguarding adults business.
  • Living well:
    • The DSAP Board aims to support partners to deliver preventative actions, to safeguard those with care and support needs through learning together and delivering change.

Copies of both of the above business plans can be found at TDSAP Work.

Our work during 2020/21

COVID-19 had a significant impact on both safeguarding adults boards and the newly merged Board and the core work that continued during the pandemic. A decision was made, in consultation with partners, to re-prioritise and strategically pause some work, to enable partners to concentrate on their pandemic response as a priority.

Despite adopting a focus on statutory assurance and support, the boards continued to maintain their Care Act 2014 obligations for safeguarding adults with regular assurance gained from their key safeguarding partners.

Partners provided assurance reports to the independent chairs including updates on their COVID-19 crisis response. This approach ensured that partners provided a proportionate strategic overview during the pandemic.

In December 2021 the Devon Safeguarding Adults Partnership and the Torbay Safeguarding Adults Board merged to form the TDSAP. This included a successful process to appoint a new Independent Chair to the TDSAP. The merger was completed in Quarter 4 of 2020/21 and since then the TDSAP has been working to ensure their policies and procedures are aligned across the new partnership.

The TDSAP has undertaken a review of Safeguarding and Mental Capacity Act training to ensure the offer from the TDSAP is up to date and in line with legal literacy. The TDSAP increased safeguarding training capacity for partners to meet increased demand following an awareness campaign launched in 2020.

The TDSAP undertook a review of the referral process for SARs as a result of an increased number of SARs being received. An evaluation criteria was introduced to ensure the process is as effective and efficient as possible.

Learning from SARs continues to be a priority piece of work for the TDSAP going into 2021/22 and beyond, as detailed in the 2021-2024 TDSAP Business Plan.

Looking ahead

The strategic priorities for the TDSAP have been agreed and published in the 2021-2024 TDSAP Business Plan.


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