Skip to main content
Home Secure area

Learning and improvement

The are several strands to our learning and improvement programme all of which are explained below:

Quality Assurance Audits

HSAB audits and reviews cases through its ongoing quality assurance programme and through in-depth reviews of cases of significant concern through which additional learning will be identified.  Where necessary improvements are identified through this work, the findings are placed on to our Audit Tracker with appropriate actions.  These are then monitored by the Board's Performance, Audit and Quality Assurance sub group.

Safeguarding Adults Reviews

We have completed one SAR to-date and the findings are contained within this 7 minute learning-

7 Minute Learning

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

How a SAR should be undertaken

Statutory guidance (para. 14.135-14.144) outlines principles that should underpin all SARs, how the SAR should be undertaken (including the skills and experience needed of those undertaking a SAR), what the SAR should aim to achieve and suggested reasonable timescales. When setting up a SAR the SAB should consider how the process can dovetail with any other relevant investigations that are running parallel, including child Serious Case Reviews and Domestic Homicide Reviews.

Statutory Duty

  • Where the SAB decides not to implement an action it must state the reason for that decision in the Annual Report (Schedule 2, 4(1)).
  • Each SAB member must cooperate in & contribute to the carrying out of a review with a view to identifying lessons to be learnt and applying those lessons in future cases (Care Act 44(5))

Findings from SARS

SAR reports should provide a sound analysis of what happened, why and what action needs to be taken. The report should be written in plain English and contain findings of practical value to organisations & professionals. Findings from any SAR should be included in the SAB Annual Report, including what actions have been taken (or intend to be taken) in relation to the findings.

Learning Lessons from Safeguarding Adults Reviews

Please click on the link below to see the HSAB procedure for Safeguarding Adults Reviews:

Serious Case Review Procedure

External reviews of our effectiveness and self evaluation

Peer Challenge Follow Up Visit Response Dec 2016 

Peer challenge review action plan

Practitioner Forums

These multi-agency events are held throughout the year and are based on subjects that practitioners have requested further knowledge of. On 19th May 2016 we held a session covering Information Sharing.