Safeguarding Adults Reviews and Learning in ABI Services

Safeguarding Adults Reviews (SARs) frequently highlight systemic issues affecting people with acquired brain injury, including poor information sharing, weak risk oversight and delayed escalation. Commissioners expect providers to demonstrate how SAR learning is actively embedded rather than passively noted.

This article explains how ABI services should respond to SARs. It should be read alongside Quality, Safety & Governance and Safeguarding, Capacity, Risk & Vulnerability.

Why SARs matter for ABI services

SARs often involve complex capacity and vulnerability factors.

Commissioner and inspector expectations

Expectation 1: Evidence of learning. Inspectors expect services to show tangible change following SARs.

Expectation 2: System-wide improvement. Commissioners expect learning to influence governance, not just frontline practice.

Operational example 1: Improving escalation pathways

A provider revised escalation guidance following SAR findings.

Embedding SAR learning into governance

Learning should be reflected in audits and training.

Operational example 2: Training refresh after SAR

Staff received targeted safeguarding and MCA refresher training.

Sharing learning across teams

SAR learning should be shared across the organisation.

Operational example 3: Cross-service learning briefings

Learning briefings were added to team meetings.

Evidencing SAR learning

Providers should evidence:

  • Action plans linked to SAR recommendations
  • Audit outcomes
  • Training and supervision records

Why this matters for inspection and commissioning

Active SAR learning demonstrates safe, reflective practice.


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Written by Impact Guru, editorial oversight by Mike Harrison, Founder of Impact Guru Ltd β€” bringing extensive experience in health and social care tenders, commissioning and strategy.

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