Dynamic Inspection of Public Protection in South West region
Chief Inspector’s judgement (Back to top)
In this inspection of public protection work conducted by Probation Services across the South West region we were concerned to find that fewer than half of cases met the sufficient standard for keeping people safe in assessment, implementation and delivery, and reviewing activity.
A key and long-standing issue across the region was insufficient multi-agency information gathering and lack of consistent approach with partner agencies, including children’s services and police.
Of particular concern were findings that critical risk-related information was not always captured and disseminated and, even when relevant information was available, it was not consistently analysed or incorporated into risk assessments.
This, along with an inexperienced workforce, meant behaviours linked to harmful behaviour and attitudes were not being adequately assessed or analysed, and critical risk-related information was not always captured and disseminated – leading to insufficient measures for risk management.
Prior to this inspection, significant changes had taken place in the region’s strategic leadership team and leaders acknowledged a need to implement and sustain cultural changes. We found an improved sense of inclusiveness across the region aligning with an improved environment for learning and being held to account for the delivery of high-quality services.
However, while it was articulated that public protection was a priority, there was no regional public protection strategy or defined priorities, actions, or accountability mechanisms. Consequently, there was a lack of clarity of what was to be prioritised. In addition, in over three-quarters of inspected cases, management oversight was insufficient, ineffective, or absent and therefore did not provide the required impact to improve the quality of work.
The leadership team was engaging with strategic partners and had identified activities to improve collaboration and promote public protection practice. However, these activities were in their infancy and had not impacted improved delivery in all cases. Further work was required to establish a national strategic approach to facilitate collaboration and overcome issues about consent and consistency.
Capacity challenges were frequently cited by regional leaders and lengthy vetting procedures, ongoing vacancies, and high workloads continued to undermine efforts to improve stability within the region. However, the issues at an operational level extended beyond workload pressures, with complex, multi-layered and process-driven core tasks that hindered effective decision making and resulted in staff being overwhelmed.
A largely inexperienced workforce, including middle managers, reported significant gaps in training. Worryingly, despite almost all staff believing they possessed the necessary skills, experience, and knowledge, this did not translate into effective management of risk within all cases.
There was also limited evidence of meaningful engagement with services and interventions to support public protection practice, including Commissioned Rehabilitative Services, Structured Interventions and Accredited programmes, and this directly impacted on the delivery of proactive work to reduce risk of harm.
Context (Back to top)
We inspected public protection work across the South West Probation region. In total, 64 cases that commenced between 28 April 2025 and 09 May 2025, were inspected, focusing specifically on the delivery of public protection activity to keep people safe. Case inspections examined assessment, planning, implementation and delivery, and reviewing, focusing on the perspective of effective public protection activity. Inspectors also considered the efficacy of the region’s organisational arrangements including multi-agency work and the use of restrictive and rehabilitative actions to support risk management. A third of the cases inspected were subject to Multi Agency Public Protection Arrangements (MAPPA) requiring robust management and oversight and demonstrating complex and varied risks factors including offences of domestic abuse, safeguarding offences committed against children, sexual harm and violence.
The South West Probation region is comprised of a vast and complex geographical area, spanning five police forces, 11 unitary authorities and 15 Children’s Services. Probation Services were delivered across nine Probation Delivery Units (PDUs): Cornwall & Isles of Scilly, Devon & Torbay, Dorset, Plymouth, Bath & North Somerset, Bristol & South Gloucestershire, Gloucestershire, Somerset, and Swindon & Wiltshire. Delivery of services within the south-west is complex, with varying challenges in terms of location, including the high cost of living in urban areas such as Bristol and Dorset, and the longer distances and fewer transport links and services available within more remote, rural communities. There are 28 courts (12 of which are Crown Courts), 10 Approved Premises and 10 prisons across the region.
The South West region was last inspected under our previous core inspection programme during 2023 and the regional inspection report was published in August 2023. Within that review senior leaders were found to have a clear strategic approach. However, concerns were raised regarding what was perceived as a divided culture, complicated by challenges in recruitment and disappointing shortfalls in the prioritisation of focused risk management work.
At the time of this inspection, the region was continuing to experience long-standing staffing challenges and was not fully resourced across all operational grades. Recruitment efforts were leading to an improving picture, although significant gaps remained. Leaders informed us that vacancy rates were exacerbated by continued difficulties with vetting procedures and the length of time recruitment took, often following national campaigns that did not meet local need. This, coupled with a relatively inexperienced workforce within sentence management, placed significant pressures upon the quality of service delivery as a whole. These resourcing challenges were undoubtedly hindering the region’s ability to deliver high-quality casework.
Inspection commentary (Back to top)
The quality of work to keep people safe was disappointing. Fewer than a third of all cases met the threshold of sufficiency for keeping people safe in implementation and delivery, and under half of all cases met the threshold in assessment and reviewing. Analysis of case inspection rationales identified multiple interconnected factors that repeatedly contributed to the shortfalls identified in public protection casework practice. These included insufficient multi-agency information gathering, both with statutory organisations such as child and adult social care, the police, or prison service and with partner agencies such as substance misuse or housing. Even when information had been requested and received, this was not always used to full effect to inform risk management in cases.
Planning was the strongest area of practice, meeting the required standard to keep people safe in 59 per cent of cases. This indicated that practitioners were able to identify and outline interventions designed to address risk of harm factors, including restrictive and control measures, and identify appropriate links to the work of partner agencies.
Positive progress had also been made with court work. In our previous inspection, court work in two out of three PDUs inspected was assessed as inadequate and as requires improvement in one PDU. In this inspection, proposals were made to court to support public protection in 59 per cent of inspected cases, and a sufficient assessment of risk of serious harm was made in just over two-thirds of relevant cases. Domestic abuse and child safeguarding information was obtained and used as part of the suitability for curfews in 15 out of 18 relevant cases. The implementation of structures and systems such as the use of pre-sentence report gatekeeping was demonstrating an improvement in quality and indicated benefits from peer-to-peer learning. The span of control for court Senior Probation Officers (SPOs) had been structured to facilitate closer engagement with practitioners and this arrangement supported more frequent observation of practice and the delivery of regular, constructive feedback to report writers.
In seven out of 17 relevant cases, pre-release work to support public protection for those leaving custody was insufficient. Inspectors found insufficient contact between probation offender managers (POMs) and community offender managers (COMs), and critical risk-related information was not consistently informing assessment or management planning. Consequently, behaviours linked to harmful behaviour and attitudes were not being adequately assessed or analysed. This gap also meant that licence conditions applied did not always align with known risks. This was a particular concern when individuals were released from prison within short time frames or directly from court. Prison and resettlement leaders acknowledged the need for a more integrated approach to enable effective collaboration between prison and probation staff, and we saw good examples of this at a strategic and managerial level. Regional leaders had initiated work to strengthen relationships and promote a holistic approach and embraced implementation of the Immediate Release Pathfinder in HMP Exeter to enhance collaboration between services to share critical risk information about remand prisoners prior to sentencing. Further action was required to establish robust governance and assurance mechanisms that ensure all staff across the two services understand how prison information sharing processes underpin public protection and work to keep people safe.
We found that gaps in public protection practice across casework stemmed from multiple and varied interconnected factors. Significant national HM Prison and Probation Service (HMPPS) policy changes, combined with responses to prison capacity pressures and delays in sentencing, had impacted on the time available, prior to release from custody, to complete sufficient public protection work. This was a particular concern for those subject to early release schemes and those subject to prison sentence disposals issued by court (those who have spent a significant period remanded in custody and released direct from court as ‘time served’). In addition, changes to recall processes risked disrupting continuity of oversight and supervision, and reduced opportunities for effective engagement with partner agencies. The implementation of Probation Reset, and subsequently Impact, had further compounded service delivery challenges. Application of these policies and the complexities they represent contributed to inconsistent practice in the cases we inspected, particularly in relation to risk management and work to keep people safe.
There were systemic barriers to effective information sharing with partners. Practitioners in some areas of the region could access only the previous 12 months of police intelligence, which meant critical risk-related information was not always captured and disseminated. Similarly, information received from children’s services frequently lacked sufficient detail to clarify the nature of the concern or who was at risk. It was particularly concerning that even when relevant information was available it was not consistently analysed or incorporated into risk assessments. These critical omissions reflected gaps in practitioner knowledge and experience, insufficient exploration and verification of critical risk factors, and limited recognition of the potential impact on victims. Of the inspected cases eligible for MAPPA, the majority were identified as being managed as Level 1 cases. Inspectors saw some positive practice, identifying a few individual practitioners who were proactive in demonstrating professional curiosity and confident in coordinating a multi-agency response to support risk management. However, this was not consistent, and some MAPPA cases had not been identified in a timely manner or reviewed in any depth, limiting the added value of these arrangements.
While capacity and workload pressures were frequently cited, the issues at an operational level extended beyond simply having too much to do. Core tasks (both nationally and regionally implemented) within sentence management were multi-layered and heavily process driven. This had created a breadth and complexity that hindered effective decision making and had resulted in staff being overwhelmed by cognitive load. The region’s workforce was largely inexperienced at both practitioner and senior probation officer grade. Almost all staff interviewed (94 per cent) believed that they possessed the necessary skills, experience, and knowledge to supervise the case, but this did not translate into effective management of risk within all cases. Practitioners often lacked essential knowledge of critical risk factors. Limited professional curiosity by probation practitioners, alongside insufficient opportunities for learning and reflection, led to an overreliance on procedural compliance, focusing on completing tasks rather than analysing information, assessing its implications for risk, and working with the person on probation to manage that risk.
The regional leadership team had undergone significant changes within the last 18 months, and, in September 2025, a new regional probation director had been permanently appointed. The senior leadership team acknowledged that longstanding cultural difficulties within the region required sustained and targeted action. Recognising the need to create a psychologically safe learning environment for all staff, the region recently adopted a Human Factors approach to embed a culture of learning, reflection, and safety. Leaders understood that a significant cultural shift would take time to be embedded. Building trust was a key priority and this included creating a supportive environment and encouraging staff to acknowledge gaps in their practice in order to develop. Encouragingly, our inspection found clear signs of progress in terms of promoting a healthy working culture. Staff and partners reported that the regional probation director’s considered, inclusive approach was leading to increased engagement and fostering individual and collective accountability across all grades.
Strategic leaders were clear that public protection work was a priority and this was supported by governance structures to provide assurance and accountability. However, many of these were in their infancy and had not yet had the desired impact. Leaders considered that all business unit delivery plans and strategies had an inherent focus upon public protection as a priority area of business. Collaborative efforts were made to promote consistency and accountability through governance arrangements which promoted innovation, collaborative performance monitoring, partnership working, and promoted staff inclusion within the organisation. Performance against national and local targets was monitored using dashboards covering key areas of work and the region had chosen to keep some metrics live, even when these were no longer required nationally, due to the significance they felt the measures made to promoting good public protection work.
Whilst it was articulated that public protection was a priority, there were no regional public protection strategy or defined priorities, actions, and accountability mechanisms. Consequently, there was a lack of clarity about what was to be prioritised. More needs to be done to develop defined public protection priorities to promote consistent, coherent messaging to inform practice and reinforce accountability for keeping people safe.
The region had established relationships with key strategic partners including police and children’s services and this had strengthened information-sharing arrangements since our last inspection. The implementation of the Domestic Abuse and Children’s Services (DACS) hub, led by the head of public protection, further enhanced collaboration. This included securing direct access for DACS across three of the five police forces and three of the 15 children’s services in the region. This had improved access to information within some PDUs, however there was not a consistent approach with all services and this had resulted in differing levels of information exchange. Consequently, enquiries were not always returned in a timely manner to support initial assessments or did not provide enough detail to appropriately identify and plan for sufficient risk management. These inconsistencies undermined the practitioners’ ability to make informed, evidenced-based decisions about risk. In our case inspections, the risk to children was sufficiently assessed and analysed in only 27 out of 57 relevant cases. Police and children’s services highlighted ongoing operational challenges, particularly around organisational understanding of public protection duties, including consent and proportionality underpinning information sharing. Encouragingly, all agencies we spoke with expressed a clear appetite for ongoing collaboration with the Probation Service to improve consistency and align practice on a regional basis.
While the completion of safeguarding enquiries had improved, inspection casework highlighted significant shortfalls in subsequent risk assessment and analysis. There were consistent recurring themes across inspection findings, internal audit, and learning from Serious Further Offences (SFOs). This included inaccurate and insufficient risk assessments, lack of professional curiosity, and insufficient domestic abuse and safeguarding practice. In response, additional training had been introduced to promote professional curiosity, but its impact had been limited.
Quality development officers (QDOs) reported that current approaches to sharing learning from SFOs, such as staff bulletins, and practice development days, were not achieving the desired impact. A quality assurance framework (QAF) had been rolled out to support SPOs in monitoring quality improvement actions, but overall progress remained insufficient. Concerns persisted about staff capacity to engage meaningfully with learning initiatives, due to workload pressures, change fatigue, spans of control and the resulting cognitive overload. QDOs reflected that the region’s ‘hot topic reflective space’ sessions, which provided a brief focused input on priority areas and created a safe space for practitioner reflection, had demonstrated positive impact.
Training provision targeted, but did not consistently meet, the intended learning outcomes, resulting in critical gaps in practitioner knowledge. Effective risk management practice demands a nuanced skill set that enables practitioners and managers to approach complex situations and engage in challenging conversations with confidence. This confidence is built through the embedding of learning in an enabling environment, with the opportunity to apply learning to practice. However, senior leaders reflected that given the pace and scale of workload at an operational level, such opportunities are no longer routinely available, representing a significant barrier to strengthening public protection work. Our casework inspection identified shortfalls in risk assessment and management that were directly impacted by a lack of confidence to explore and address identified concerns, particularly attitudes and behaviours underpinning sexual and violent offences. We also identified a reticence amongst some practitioners to take timely and consistent enforcement action and this undermined the capability of the region to manage the risk of both further offending and harm.
Vacancies at all staffing grades were significantly impacted by delays in recruitment that were in part caused by vetting processes taking too long. Leaders reported that this often resulted in the successful applicant accepting a different role elsewhere which then led to a cycle of long, and ultimately fruitless, recruitment campaigns where vacancies remained unfilled.
Alongside the offer for Probation Qualification in Practice (PQIP) learners, ongoing learning and development needs for newly qualified probation officers and PSOs had been identified. The region had implemented delivery of a rolling programme for new entrants to the service. However, the majority of operational practitioners within the region only had between two and five years of experience. This is significant given that national and regional training offers are primarily targeted at staff with fewer than two years in post and the improved training offer had not been in place for that long. This misalignment created a gap in development opportunities for a substantial proportion of the workforce. Further disparities in the training provision professionals experienced prior to unification of services, compounded by disruption during the Covid-19 pandemic, continued to affect practice quality and the ability to achieve consistent standards.
Senior leaders had enabled heads of PDUs to have the freedom to balance staffing levels of probation officer and PSO grades according to their needs, however they had been unable to recruit sufficiently to either grade. Consequently, workloads were high, creating additional pressure on staff already working over capacity. Operational leaders were candid, stating to inspectors,“we are running just to stand still”. They suggested that workload pressures, combined with the pace of change and an overreliance on performance metrics, had resulted in an inability to gain any traction on the improvements needed in public protection practice. To assist in the demands on practitioners, the region was developing a practice ‘hub’, which will pick up administrative and case related tasks that can be completed by others than the practitioner in the case. Albeit in its infancy, this has potential to enable leaders to provide a more dynamic response to identified staffing capacity issues and improve consistency of practice across the region.
Of our inspected cases, 22 were MAPPA eligible, with the majority (20) managed at Level 1. However, only eight of these cases demonstrated evidence of coordinated, multi-agency oversight, including joint working with the police. There were also disparities between PDUs in the sufficiency and quality of how MAPPA cases were identified and managed. Regional data highlights persistent challenges in securing attendance from children’s services and duty to cooperate agencies at Level 2 and 3 meetings, alongside inconsistent provision of MAPPA contributions from prison representatives. Governance and assurance processes for Level 1 cases remain unclear and inspectors were unable to obtain figures on the backlog of Level 1 reviews. Our fieldwork identified there were concerns about the quality of some Level 1 reviews and ongoing confusion regarding roles and responsibilities. While this was partly linked to practitioner and middle manager experience and knowledge, greater clarity regarding processes and expectations was essential to strengthen oversight and ensure consistent practice in this key area of work.
Interventions teams, particularly at a strategic level, were cohesive, clear on their remit and demonstrated a clear understanding of how each intervention could and should contribute to effective risk management. The inclusion of electronic monitoring within the intervention portfolio was a strength. However, at the time of inspection, evidence showed limited use of specific interventions to underpin public protection practice. Commissioned Rehabilitative Services and structured interventions, including accredited programmes, were underutilised or not fully understood as mechanisms to support the management risk. Delivery of services to support the safety of other people effectively was sufficient in only 30 per cent of inspected cases. Practitioners often lacked the confidence and/or knowledge to undertake offence-focused work with people on probation on a one-to-one basis, resulting in insufficient meaningful activity to address harmful behaviours effectively.
Management oversight was insufficient, ineffective, or absent in over three quarters of inspected cases and did not provide the required impact to improve the quality of work being delivered. The region had introduced a Quality Assurance Framework (QAF) to support managers in strengthening oversight; however, this had been perceived as additional administrative burden by managers already facing resourcing pressures. High workloads, inexperience at middle manager grade, and the impact of a period of extensive policy changes, constrained SPOs’ capacity to implement tailored quality assurance and oversight systems that met the needs of a developing workforce. Practitioners required greater clarity on what they were accountable for, how this translated into responsibility for public and victim safety, and a mechanism where gaps in their practice could be identified to enable targeted training opportunities.
Regional recommendations (Back to top)
- Ensure mechanisms are in place to provide effective governance, assurance, and oversight of MAPPA-eligible cases at all levels.
- Evaluate and strengthen the delivery of interventions and services to support public protection practice.
- Complete a learning needs analysis with PSO, PO and SPO grades, to understand their skills, confidence, and knowledge to adequately assess, work with, and review risk of harm to others, and ensure effective training is provided to meet these needs.
HMPPS recommendations (Back to top)
- Develop a national strategic approach to information sharing with police and children’s services to support regions in achieving consistency and compliance with legislation to obtain and use information to protect the public.
- Evaluate current national performance metrics to determine whether they drive quality public protection practice and consider how to embed public protection-specific metrics in dashboards to enable leaders to monitor quality and impact effectively.
- Reduce vetting delays and address workforce instability by implementing streamlined and more responsive recruitment processes.
Scoring (Back to top)
| Key question | Percentage ‘Yes’ |
| Does assessment focus sufficiently on keeping other people safe? | 45% |
| Does planning focus sufficiently on keeping other people safe? | 59% |
| Does the implementation and delivery of services effectively support the safety of other people? | 30% |
| Does reviewing focus sufficiently on keeping other people safe? | 39% |
Follow-up activity (Back to top)
In line with the recommendations identified, a range of follow-up activity will take place. HM Inspectorate of Probation will work with the region to identify what can be done to guide and support their work, increase knowledge and confidence, and provide a solid foundation for further improvement. The Inspectorate will also seek to share what effective practice looks like by drawing upon inspection findings, identify blockers to progress, and highlight opportunities to improve accountability.
Key contextual facts (Back to top)
| Number of people supervised (on 30 June 2025)1 | 16,821 |
| MAPPA-eligible offenders (on 31 March 2025)2 | 7,963 |
| Victim satisfaction performance SL021 (April 2024 – March 2025)3 | 72.9% |
| Staffing level (Staff in post full time equivalent (FTE))4 | ||
| Senior probation officer (PSO) | Probation officer (PO) | Probation services officer (inc. Professional Qualification in Probation (PQiP)) |
| 88% | 89% | 85% |
| Average Caseload at the point of inspection (FTE) | ||
| PO | PSO (exc. PQiP) | PQiP |
| 36.21 | 48.49 | 35.31 |
| Recall rates (in the 12 months prior to inspection) | 21.47% |
| Average rehabilitation activity requirement (RAR) wait time (in the 12 months prior to inspection) | Not available |
| Percentage of RAR days completed (in the 12 months prior to inspection) | 51% |
| Percentage of accredited programme requirements completed for individuals convicted of a sexual offence (in the 12 months prior to inspection) | 19.71% |
| Percentage of accredited programme requirements completed for individuals not convicted of a sexual offence (in the 12 months prior to inspection) | 40.24% |
| Risk of Serious Harm classification of inspected cases | ||
| Low | Medium | High/very high |
| 5% | 63% | 28% |
Data annexe (Back to top)
Press release (Back to top)
Further information (Back to top)
This inspection was led by HM Inspector Joy Wilson, supported by a team of inspectors and colleagues from across the Inspectorate. We would like to thank all those who helped plan and took part in the inspection; without their help and cooperation, the inspection would not have been possible.
Footnotes
- https://www.gov.uk/government/collections/offender-management-statistics-quarterly. ↩︎
- https://www.gov.uk/government/collections/multi-agency-public-protection-arrangements-mappa-annual-reports. ↩︎
- https://www.gov.uk/government/statistics/community-performance-annual-update-to-march-2025. ↩︎
- Workforce data included in this report come from internal management information and some of these data have been derived from a different data source to the published HMPPS Workforce Statistics bulletin and accompanying Probation Officer Recruitment Annex. The Inspectorate needs access to the latest data available and internal management information is deemed the best source to allow this. As such, there could be discrepancies between the data in this report and the data contained in the publication. ↩︎