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Torbay & Devon Safeguarding Adults Partnership Annual Report 2021/22

Section 1: Chair's foreword

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

All of the Board members and agencies that are represented on the Torbay and Devon Safeguarding Adults Partnership have worked hard over the last twelve months to deliver against the priorities that were set in 2020/21. The Partnership has reviewed these priorities and there was universal agreement that they remain relevant to the work that needs to take place over the next twelve months.

The last twelve months have seen the TDSAP subgroups establish themselves in terms of the work that is needed to progress to deliver the priorities. Workplans have been set and are regularly reviewed by the Partnership members to ensure that we are working constructively together to improve the services in both Devon and Torbay. We have also spent this time to look at our quality assurance processes which will enable us to know whether we are actually making a difference. We will continue to work with the Community Reference Group to ensure that the work is meeting the expectations of the individuals and their families that use our services. Where possible we have also been working together with the other Boards in both areas to reduce duplication and streamline the work that we are seeking to deliver.

I continue to be impressed by the commitment of all of the TDSAP members  to sustaining the work of the Partnership.

Section 2: Our purpose

The Torbay & Devon Safeguarding Adults Partnership (TDSAP) is the collective name for the partners that work with the Board to safeguard adults across Torbay and Devon.

The TDSAP provides strategic leadership for adult safeguarding across Torbay & Devon and is 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 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 co-ordinating what each of the TDSAP members does and ensures that they do it effectively.

Section 3: Our structure

The TDSAP undertook a review of its sub group structures to ensure that they remained fit for purpose to deliver the priorities contained within the Strategic Business Plan 2021-2024 and to continue to meet our requirements as laid out in the Care Act 2014.

Following the review, a revised structure was agreed as per the diagram below. This refreshed structure ensures that each group has the effective terms of reference, membership and governance in order to meet our business aims.

These meetings will continue to be supported by the Partnership Practice Lead, Partnership Business Manager and Partnership Co-Ordinator.

Section 4: Our partnership members

4.1 Statutory partners

The statutory partners of the TDSAP are: Devon and Cornwall Police, Devon County Council, Torbay Council and NHS Clinical Commissioning Group (NHS Devon)

On 1 July 2022 NHS CCG became NHS Devon Integrated Care Board (NHS Devon)

4.2 Partners

Other partner members of the TDSAP are:

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

Section 5: Safeguarding activity

5.1   Safeguarding Concerns

The trend in the number of adult safeguarding concerns has been different in Devon and Torbay over the past couple of years.

In Devon and Torbay there was an increase in the number of reported safeguarding concerns. This coincided with the global covid pandemic and the publication of the national guidance in 2020/21 which attempted to standardise practice of what constitutes a concern.

In Devon the numbers of concerns have continued to rise, however in Torbay the number of concerns has remained at the same level in 2021/22.

While both authorities have seen an increase in the number of reported concerns, both are still under the national rate.

5.2   Safeguarding Enquiries


The number of safeguarding adults enquiries, (concerns that meet the criteria for further section 42 enquiries) undertaken by both authorities, has increased over the last three years.

In Devon during 2020/21 the number of concerns raised which did not meet the criteria for a section 42 enquiry increased. This increase was due to both change in guidance on recording practices and more referrals received during the pandemic that did not necessarily require a safeguarding response. All of these referrals were directed to more appropriate pathways.


In Torbay the pattern follows much more closely to the changes seen in the numbers of concerns raised. Both authorities are again below the national rate for section 42 enquiries.

59% of individuals in Devon and 58% in Torbay involved in safeguarding concerns in 2021-22 were female. This is consistent with previous years and the national trend. This is disproportionate to the overall Devon and Torbay population, although not necessarily the elderly population which most of our safeguarding activity relates to.


Approaches to safeguarding should be person-led and outcome-focused. In Devon 83% and in Torbay 82% of people were asked about their desired outcomes in safeguarding enquiries in 2021-22.


86% of individuals in Devon and 69% in Torbay involved in safeguarding concerns in 2021-22 recorded their ethnicity as white. The proportion of people in Devon who describe themselves as white British increases with each age group and safeguarding data on ethnicity should therefore be considered in conjunction with data on age. This data shows that the majority of safeguarding concerns in Devon relate to individual’s aged 65+.


60.5% of safeguarding enquiries pursued in Devon and 50% in Torbay in 2021-22 took place within the person’s own home. This has been rising for both authorities over the past couple of years and for Devon is now a higher proportion than the national picture (47.6% in 2021-22).

The proportion of enquiries recorded in care homes has fallen in 2021-22 to 22.6% in Devon putting it below the national proportion of 32.2%. The Torbay proportion has also fallen though is still above the national proportion at 38.1%.

For both Devon and Torbay the most common source of risk are Neglect and Acts of Omission (18% in Devon and 20% in Torbay) or Psychological Abuse (18% in both Devon and Torbay). This is different to the national picture where the most common sources of risk are Neglect and Acts of Omission (31%) and Physical Abuse (18%).


The TDSAP has and will continue to monitor this data to identify trends and learning that can improve service delivery.

Section 6: 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.
SAR activity is managed through the SAR Core Group. The Core Group meet on a quarterly basis and is attended by representatives from partner organisations including NHS Devon, Torbay County Council, Devon County Council and the Police.
SAR activity during 2021/22

There have been 4 SAR referrals during the period of 2021-2022 which met the Care Act Criteria for a SAR.

The themes from these referrals include:

  • Mental Health (any support that people receive to protect or promote their mental health and psychosocial wellbeing).
  • Coercive Control (acts of assault, threats, humiliation and intimidation or other abuse that is used to harm, punish, or frighten a person).
  • Cuckooing (the practice of taking over the home of a vulnerable person in order to establish a base for illegal drug dealing).
  • Neglect/Acts of Omission (the failure to meet individuals basic and essential needs, either deliberately or by failing to understand these).

In 2021/22 the Torbay and Devon Safeguarding Adults Partnership completed 2 SAR’s. In both cases a decision was made by TDSAP members not to publish the SAR reports on our website. These decisions were made following a review of the circumstances in each case and representations made by family members.

The TDSAP held a number of learning events during the year. These included a SAR Learning Workshop on 2nd March 2022 where multi-agency partners attended to discuss and consider the learning from recent SAR’s. The event was well attended and was facilitated by members of the SAR Core Group. The feedback received from those who attended was extremely positive with participants commenting that they had really benefitted from the event.

Future learning events and workshops are being planned for 2022/23 as well as sharing SAR learning briefs and podcasts to aid front line operational staff understand the new learning from completed SAR reports.

More information is available on our website about the TDSAP SARs, including copies of previously published SARs as well as guidance on SAR Thresholds and how to complete a SAR Referral.

Section 7: TDSAP sub-groups

7.1 Community Reference Group

The 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 takes direction from the TDSAP to undertake co-production, consultation and engagement work. Methods to gather intelligence have included focused task and finish groups, on-line 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.

During the year the CRG brought the voice of the service user into Board meetings via video and other innovative approaches to ensure that the voice of the people we support, remains central to the planning of future partnership priorities.

7.2 Learning & Improvement Sub-Group

In response to the restructure of the TDSAP sub groups, the terms of reference for this sub group have also been reviewed and streamlined to ensure that this group supports the Strategic Priorities of the Torbay and Devon Safeguarding Adults Partnership.

The revised terms of reference ensure the group focuses on delivering the business activities in relation to Learning, Improvement of Practice, Training and a key focus on action planning from our Safeguarding Adults Reviews (SARs).

In addition, the group has maintained a focus on all other learning opportunities including learning from SARs outside of our area.

The Learning and Improvement sub group continues to monitor closely the Partnership Training Offer and uptake from Partners, including the private, voluntary and independent sectors. The demand continues to be high generally for all course presentations.

All training courses are running well, with good attendance and all course presentations remain virtual with a further review planned in the near future. 

7.3 Performance and Quality Assurance Sub Group

The newly formed Performance and Quality Assurance (PQA) Subgroup supports the Torbay and Devon Safeguarding Adults Partnership to take a strategic overview of the performance and quality of safeguarding activity across Torbay and Devon.

The group met for the first time in early 2022 and developed a clear terms of reference and a strong and robust Quality Assurance Framework, to provide the structure to ensure the group meets it aims.

The Quality Assurance Framework is underpinned by the Care Act Safeguarding Principles, and includes the expectation that learning from quality assurance will be shared with partners to bring about positive change to practice and improve outcomes for adults and their carers.

The PQA supports the partnership in looking at what we do, how well we do it and what difference we make to operational systems and processes.

The group regularly reviews safeguarding adult performance data and undertakes an in-depth review of the Annual Safeguarding Adult Collection Data, published each September, to identify areas where specific assurance is required.  

7.4 Operational Delivery Group

The TDSAP Operational Delivery Group (ODG) is responsible for delivering the activities set out in the TDSAP Business Activity Plan.

The group regularly considers safeguarding adults multi-agency practice, process and systems across Torbay and Devon to ensure that there is effective communication and quality working practice in place. The ODG does this to ensure that members of the public and service users are protected from potential abuse and harm.

The ODG works closely with the sub-groups of the Partnership to ensure that any potential duplication is minimised.  This will be achieved through close communication between the TDSAP, this group and the Chairs of the individual sub-group.

A key purpose of the ODG is to ensure that the Learning and Improvement Sub Group, Performance and Quality Sub Group and the Community Reference Sub Group report directly to the ODG on progress of priority activities from the respective sub groups.

The ODG is the engine room of the Partnership, by controlling and directing the work of the sub groups. The ODG meets quarterly and reports directly into the Partnership Board.

Another key purpose of the group is to drive the implementation of the business plan on behalf of the TDSAP.

During the past 12 months, the group has had excellent representation from across the partnership and demonstrated a strong commitment to shared ownership of the Partnership agenda.

Section 8: TDSAP priorities 2021-24

The Strategic Priorities for the TDSAP were agreed at a Development Day in July 2021. The Development Day was attended by TDSAP Partners and thus allowed a wide contribution from across Torbay and Devon. The TDSAP agreed four priorities as listed below which were published in the 2021-2024 TDSAP Business Plan.

The priorities are detailed below:

Strategic priority What we will do to deliver this priority
To embed the learning from Safeguarding Adults Reviews (SARs) into organisational practice
  • Partners will contribute to the SAR process and play a key role to identify the relevant learning
  • We will embed a process to identify immediate learning and implement this swiftly
  • We will ensure the learning is SMART with key success criteria in place
  • Partners will provide strong evidence to assure the TDSAP that sustained improvements have been embedded
  • Promote multi-organisational communication, ensuring cooperation as an underlying key principle
  • Develop swift and dynamic processes for delivery of Safeguarding Adults Reviews
  • Each Safeguarding Adults Review will have an underlying principle to ‘Focus on the Learning’ for each organisation
  • We will regularly monitor, identify and resolve reoccurring SAR themes to prevent reoccurrence
To work with partners to better understand and reduce the risk of ‘hidden harm’, especially in the context of COVID-19
  • Support and encourage all safeguarding partners to focus on the ‘Hidden Harm’ that is usually out of sight from public view and often not recognised or reported
  • Ensure that the emphasis is on having a culture of ‘spotting early signs’ to prevent risks escalating
  • Use COVID 19 data and information to seek assurance that partners are all uncovering and responding to hidden harm
  • Ensure that all safeguarding partners who work with people who have needs for care and support, exercise professional curiosity and take appropriate action
  • Embed the theme of ‘professional curiosity’ within multi-agency case audits (MACA)
  • Develop and deliver a multi-organisational workshop and awareness campaign for partners and service representatives to better understand, encourage and support professional curiosity and escalation within their organisations
To improve outcomes for people with needs for care and support by finding the right solution for them
  • To seek assurance that partners and service representatives work together to establish more effective coordination to achieve person centred solutions
  • Work with partners and service representatives to better understand and embed a creative approach to finding effective solutions for people with complex lives
  • We will develop and share key data and information to help develop effective communications and co-ordination between partner organisations, including strengthening links with the districts and community safety partners
  • We will focus on preventative strategies to better understand how we can avoid the need for safeguarding intervention
  • We will work with service representatives and commissioning partners to better understand people’s needs and support them to achieve their desired outcomes
  • To have regular assurance from partners that people are safeguarded during and after the COVID-19 pandemic and that attention to safeguarding continues in accordance with statutory responsibilities, recognising that some people will be put at greater risk as a consequence of the pandemic
Improving involvement and engagement with people in receipt of safeguarding services
  • We will build on past Safeguarding Awareness Campaigns by targeting communications within our communities to raise further awareness of safeguarding
  • We will learn from COVID 19 experiences and use this feedback to shape future engagement
  • We will work with key partners to improve the interface with children’s services especially for those who transition to adult services
  • To seek assurance that all partners are involving and listening to people about their experience of safeguarding
  • Ensuring that all people are listening to, valuing and responding to relatives, friends and people in communities
  • The partnership will have a focus on ‘Making Safeguarding Personal’ to ensure that safeguarding is person-led and outcome-focussed
  • We will continue to invest and engage with community groups to ensure the ‘voice of the person’ is central to partnership working


Section 9: Key partner achievements during 2021/22

Below is a selection of the key partner achievements, in relation to safeguarding adults, during the year:

9.1   Devon County Council (DCC)

  • Integrated Adult Social Care (IASC) and Children Social Care have jointly commissioned a 3-tier domestic abuse training package. The work was put out to competitive tender and was won by a partnership of three of Devon’s specialist third sector domestic abuse organisations. Development of the training package has been a truly collaborative piece of work. There has been much sharing of expertise between the three domestic abuse services and our own workforce development team and a valuable increased level of understanding. This will positively contribute to the delivery of the TDSAP Strategic Priority for Hidden Harm.
  • IASC worked in partnership with the Devon Care Home Collaborative (DCHC) and TDSAP partners to develop practice guidance for organisations who provide care and support. The documents relate to frequent occurring situations and provide guidance as to what might possibly be the next steps including whether a referral for a safeguarding adult concern should be made. The guidance developed is as follows:
    •  A quick guide for when to raise a safeguarding concern
    • Safeguarding Adults and Medicines Management – Guidance for organisations who provide care and support
    • Falls and safeguarding – Guidance for organisations who provide care and support
  • In partnership with The Heart of the South West Trading Standards, IASC have embedded the National Friends Against Scams E-Learning initiative as part of our Level 1 Safeguarding Adult training offer for practitioners. Concerns relating to scams increased during the pandemic, which is why this initiative was considered a priority.

9.2   Torbay and South Devon NHS Foundation Trust (TSDFT)

  • We formed our integrated care organisation in October 2015 when we became the first NHS organisation in England to join-up hospital and community care with social care. We are proud pioneers in integrating health and social care nationally. TSDFT supports around 500,000 face-to-face contacts with patients in their homes and communities each year and see over 78,000 people in our A&E department annually. We serve a resident population of approximately 286,000 people, plus about 100,000 visitors at any one time during the summer holiday season.
  • Our services include a delegated responsibility from Torbay Council for adult social care services in Torbay including safeguarding adult legal duties.  We often see the benefit of our integrated services in our local safeguarding system by providing timely health and social care team responses to many of the safeguarding concerns we receive.  During the past 12 months, we have enhanced our safeguarding system by integrating our Safeguarding Adult Single Point of Contact team within our Front-Door / Intake team.  This has enabled us to develop our systems to ensure responses are more streamlined and efficient.
  • As a regulated service we continue to place safeguarding patients from abuse and harm as a priority.  We have extended our range of resources available to teams such as Mental Capacity Act resource packs and briefings, as well as reviewing our safeguarding governance process to strengthen our collective workplan activity.  Examples of how we have improved patient experience include enhanced support for patients for example with dementia, as well as patients who have experienced domestic abuse.
  • As an organisation that covers Torbay and Devon geographical boundaries we continue to see the value in the new Torbay and Devon Safeguarding Adults Partnership (TDSAP) in creating a consistency of approach in local safeguarding arrangements.  We very much value being part of the TDSAP and will continue to support its arrangements as needed.

9.3   Devon and Cornwall Police

  • We have introduced  the Strategic Safeguarding Improvement Hub (SSIH) which is a multi-disciplinary team made up of both police officers and police staff with extensive safeguarding, public protection and investigative experience who work to deliver improvements in working practices They will also identify training needs, take the learning from SARs and Domestic Homicide Reviews and ensure recommendations are taken forward across the organisation and identify national good practice across the 13+ strands of vulnerability.
  • We have also  completed a survey of frontline staff to measure baseline understanding of the Mental Capacity Act. This will identify training needs but has also been used as an opportunity to sign post staff to the College of Policing MCA guidance for police officers.
  • With the introduction of Niche Needs Explanatory Note, all officers will shortly be receiving training on completing Public Protection Notices (PPN) with a specific focus on Adults at Risk. This training will include wider safeguarding adults themes such as the ‘voice of the adult’, ‘spotting the signs of hoarding/self-neglect’, ‘making a safeguarding referral’, ‘the Mental Capacity Act’, ‘Adult Criminal Exploitation’, ‘Modern Slavery/Human Trafficking’ and ‘Hate Crime’.

9.4   Devon Partnership Trust

  • During 2020-2021 the Trust completed 316 safeguarding adults enquiries (compared with 227 in 2019-2020) and increase in activity of 39%.
  • We have embedded a Restorative and Just Learning Culture (MerseyCare NHS Trust) into our Managing Safeguarding Concerns about Staff process; this is now an appendix to the Promoting a Positive Work Environment Policy – Restorative Just and Learning Culture :: Mersey Care NHS Foundation Trust)
  • We have also introduced Memory Capture Forms for use following incidents and safeguarding concerns on wards.
  • The Trust has developed new policies and guidance for staff on:
    • Safeguarding Supervision
    • Social Media
    • Managing disclosures of historical abuse
  • The Trust has also designed and implemented new training on professional boundaries for staff following learning from safeguarding enquiries

9.5   NHS Devon

  • NHS Devon have developed and delivered Safeguarding Adult Level 3 training to supplement the online Health Education England Course. This has improved staff’s confidence in responding to safeguarding enquiries.
  • We have strengthened our links with the independent healthcare providers from whom we commission services through the development of an Independent Safeguarding Forum. This enables us to deliver peer safeguarding supervision and respond to individual requests for support.
  • NHS Devon appointed a named GP for safeguarding in the summer of 2021. The named GP has enabled NHS Devon to strengthen the support provided to general practice. This is improving the quality of individual responses to safeguarding enquiries.

9.6   University Hospitals Plymouth NHS Trust

  • Our safeguarding integrated “Think Family” service has continued to improve and evolve in 2021/22. Notwithstanding the enduring COVID pandemic and the significant unprecedented national demands seen by acute hospital(s) and health services, we have maintained a robust, reactive and effective safeguarding service.
  • With executive support and resourcing we are ready to embrace the statutory changes in the long-awaited Liberty Protection Safeguards and the impact anticipated for our large acute organisation.
  • The acquisition of a health Independent Domestic Violence Advisor (IDVA) has provided a specialist clinical on-site dedicated worker who we can say with confidence has saved lives in 2021-22.

9.7   Royal Devon University Healthcare NHS Foundation Trust

On the 1st of April 2022 Royal Devon & Exeter NHS Foundation Trust and Northern Devon Healthcare Trust merged to become Royal Devon University Healthcare NHS Foundation Trust. These achievements are reflective of both organisations.

  • MyCare, an electronic healthcare record, has now been introduced across all Royal Devon services in the North and East. This will deliver improved communication across all services, including supporting safeguarding practice information sharing and partnership working. There has been a focus on supporting discharge planning when safeguarding concerns have been raised.
  • We have continued support of workforce development through education and training, particular focus on self-neglect, domestic abuse and including the Mental Capacity Act (MCA) and Liberty Protection Safeguards (LPS).
  • Attendance at TDSAP learning events and SAR practice events have supported practice.
  • We are flexible and responsive to change, working actively towards greater awareness of the impact of trauma on peoples’ live. We have hosted a study day and participate in the Devon Trauma Network.
  • The Trust has invested in MCA/LPS Teams to support practice and prepare for LPS introduction next year.

9.8  Probation Service

  • In Devon and Torbay we have ensured all staff have completed their Safeguarding Adults Training.
  • We have started a quarterly “ Focus on Safeguarding “ session where we disseminate learning from Safeguarding Adults Reviews.
  • We are focussing on supporting staff to complete more home visits so that they can assess neglect or any other risk factors in individuals homes.

9.9  HM Prisons

  • Buddies – The Buddies work alongside healthcare and prison officers to help support and care for their peers as part of a collaborative service. The Buddies consistently demonstrate their passionate commitment to help others, empowering those vulnerable around them to maintain their independence.
  • Listener’s Scheme – We have introduced a  peer-support scheme within prisons, which aims to reduce suicide and self-harm. Listeners provide confidential emotional support to their peers who are struggling to cope or feeling suicidal. They are selected for the role by Samaritans volunteers and receive intensive training based on the training that Samaritans’ volunteers undertake.
  • Peaceful Solutions – This is a confidential peer led process for all to be fully heard and understood in order to find change through choice rather than enforcement. Generally accessed by those in crisis or in need of additional support, a meeting is held with a trusted and trained facilitator to talk through the issue or conflict with an aim of supporting and agreeing a peaceful solution.
  • We have an overarching Safety strategy which incorporates safeguarding, and sign posting.
  • We hold bi-weekly meetings with local authority (DCC Social worker & OT with PPG) regarding vulnerable prisoners to ensure safeguarding issues are avoided via robust referrals.

Section 10: Looking ahead

The TDSAP Board and its sub groups will continue to manage, monitor and deliver the aims of the 2021-2024 strategic priorities, which were reviewed in the Summer of 2022 and will be reviewed again in 2023 to ensure they remain fit for purpose.


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