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Safeguarding Adult Reviews in Rapid Time (SARiRT) – learning from early implementation: key messages from the report

This page provides a summary of the ‘Safeguarding Adult Reviews in Rapid Time (SARiRT) – learning from early implementation’ report.

Evaluation of the new model

The SAR in Rapid Time (SARiRT) model provides a methodology, process and tools for undertaking a Safeguarding Adult Review (SAR) in a shorter timeframe than is usual. Many SARs can take up to six months to complete. The SARiRT model is designed to produce systems learning, which moves from the learning about the individual case to better understand the functioning of the safeguarding system.

The model aims to facilitate learning at organisational, agency and possibly cultural levels with the potential to impact on service operation, delivery and receipt. The approach was piloted in 2020 with a small number of Safeguarding Adult Boards (SABs) across England. The new model provides a methodology to support a more rapid SAR process using a systems approach with related tools for each stage in a SAR from review scoping to reporting findings. Knowledge of the systems approach reduces tendencies to blame individuals and agencies.

SCIE support during the pilot phase consisted of a one-day training course, group supervision during the process and coaching sessions as needed. This study explores the experiences of those who have used the SAR in Rapid Time model. The central research questions were:

  • What conditions allow the SAR in Rapid Time model to be used with high fidelity and remain true to the principles of a systems approach to learning from practice?
  • How effectively have SARs that used the model with fidelity been able to draw out systems learning?
  • Where systems findings were identified, did they make a difference?

Outcomes from the evaluation

Key messages

  • Initial attitudes and receptivity to the systems approach incorporated within the model were generally positive.
  • SABs who tried the new model were keen to achieve quicker, proportionate learning and improvement, and to undertake their SAR closer in time to the incident.
  • SABs with an existing knowledge of a systems approach felt more comfortable with the methodology. Though use of and adherence to a systems approach becomes easier with familiarity.
  • The SARiRT model can also be used with more complex cases.
  • An efficient use of the model called for high skills, knowledge and expertise in SAB business managers, chairs and SAR reviewers.

Factors that supported SABs to follow the new process

  • Careful consideration of the suitability of the case and required learning.
  • An existing knowledge of systems approaches.
  • Use of and adherence to SCIE templates and tools. ‘It’s hard to go wrong if you keep to the process’ (SAB 2).
  • Using the training and support received from SCIE during the process. Supervision with SCIE was described as vital.
  • Timely provision of supporting information and documents.
  • A supportive SAB and partner agency networks.
  • Being able to achieve a ‘safe environment’ atmosphere in workshops.

Factors that hindered SABs in following the process

  • Some SABs found the time frames associated with SARiRT too demanding. The time frame was initially intended to be 15 working days, however current training makes it explicit that the SAR in Rapid Time model does not prescribe a rigid timeframe; the time taken is for SAB commissioners and boards to decide.
  • Reaction to the format of the final report was mixed. SABs already familiar with the ‘questions for the board’ format (used in place of report recommendations) liked this way of encouraging board members to engage with the findings. Though other SABs missed the more traditional-style recommendations in the SARiRT report. This opinion may change as the SAR in Rapid Time model and style becomes better understood.

How far were the SABs able to achieve systems improvement using the model?

The evaluation considered SAB annual reports to gather evidence of how the learning and action plans from the SARs in Rapid Time model resulted in improvements to local systems. Where evidence was available it confirmed a broad mix of improvement work including:

  • Training – including legislation, communication, agency roles, assessment, safeguarding, mental health and risk.
  • Process changes – changes to organisational processes were made in three SAB areas (e.g. relating to information collection and to referral mechanisms).
  • Multi-agency policy and strategy development/revision – was evidenced in three SABs (e.g. the creation of a new practitioner role and an increase in community resources).
  • Staff support and guidance – three SABs improved staff guidance or made plans to do so (relating to both single agency guidance and multi-agency guidance).
  • Better agency interaction/collaboration – one SAB increased inter-agency meetings and developed a new consortium to bring relevant agencies together.
  • New database – one SAB created a new database to help service placement and monitor service user need.


  • The study found a very positive attitude towards the new model, with wide agreement that other existing models resulted in longer SAR processes.
  • Conditions that particularly helped the SAR in Rapid Time model be used as intended included having supportive SABs and affiliated organisations, attending the SCIE training, using the tools and templates provided and accessing the support offered by SCIE during the SAR process. As the SAR in Rapid Time model is a new approach, support from systems approach experts helped during the process.
  • Existing knowledge of a systems approach was a positive factor. For agencies and individuals who understood the concept well, the approach made sense and they already appreciated the value of its use.
  • In all instances where the model constructs and processes were followed, the report findings were systemic in nature. All SABs who displayed high levels of fidelity to the model were able to use SAR systems findings to successfully make or plan improvements.
  • In relation to the style and content of the final report, some SABs found the brief case specific account detail difficult, however the SAR in Rapid Time model developer advised that it is possible to extend the length of the final report to include additional case specific detail if needed. This does not compromise the model as long as a focus on systems learning still remains central.
  • The study found the SAR in Rapid Time model to be acceptable and usable by most SABs taking part. When considering whether or not to use the model, it may be helpful for SABs to know that not all of the other elements of the model have to be completely adhered to. However, any such considerations should be balanced against the purpose of the SAR in Rapid Time model which is to generate a fast review that facilitates quick learning and positive changes.

Response from SCIE Safeguarding Audit and Review Team

We would like to thank Annie Williams, an independent auditor commissioned by SCIE, who undertook the initial evaluation and all the SAB members who gave their time to take part in the evaluation, which has provided valuable insights into how the new model has been used so far. We are keen to support the sector to build on their use of a systems approach to learning, and to further embed the use of the new model. In response to the conclusions:

  1. SCIE will be delivering further free training on the new model in summer/autumn 2023 and again in spring 2024 (funded by the Department of Health and Social Care) to support SABs to use internal reviewer capacity to undertake proportionate and impactful SARs. Details and dates will be added to the SCIE SARiRT webpages in May 2023.
  2. SCIE is developing a new coaching offer to support reviewers who are new to the SARiRT model and having undertaken the SARiRT training would like to undertake their first review with some support. Details will be added to the SCIE SARiRT webpages.

If you would like further details or to discuss these two options please contact Alison Ridley (Programme Manager, Safeguarding Audits and Reviews).


Appendix 1 – study methodology

The study time span ran from the development of The SAR in Rapid Time model in 2020 through to January 2023. During this period 11 SABs took part in pilots and nine of these have participated in interviews, supplemented by analysis of the contributions of two SAB chairs to a recorded SCIE webinar. The SAR in Rapid Time reports were examined in addition to any associated SAB annual report where there was evidence of how the SAR learning had been implemented.

Appendix 2 – key elements of the SARiRT process

The early analysis report

The early analysis report provides an initial opportunity for the reviewer(s) to collate data and begin to identify emerging themes, issues and possible gaps in data, and provides a prompt to be used in the workshop. Message from the evaluation: some individuals found the early analysis report difficult to understand and use initially. However, for most, use of the report improved as they became familiar with it and started to understand the systems perspective better. Overall, opinion was that the report template produced well structured, useful documents but it was important that participants read it before the workshop

The workshop

The multiagency workshop brings together practitioners and frontline managers with direct involvement and knowledge of the case. The purpose of the sessions is to explore what happened and the factors that influenced practice. Message from the evaluation: most workshops went well. Key to workshop success were the organisational skills of those who set up the meetings, and the chairs and reviewers who kept discussions on focus. The workshop agenda template also helped as, where used, it ensured that the workshop discussion included all relevant topics and that they were discussed quickly.

The findings report

The findings report is quite short and includes only a brief focus on the individual case. It moves on to focus in more detail on the systems findings. It provides an outline of systems learning with questions posed to the board, to support a move beyond case-specific issues. Message from the evaluation: a positive factor was the ‘readability’ of the reports; they were succinct and answered the scope of the review. There were high levels of support for the identification of systemic factors, and within this the supervisions with SCIE were seen as very important. However some SABs were critical of the reduced focus on the individual case account details.

Questions to the Board

Traditionally a set of recommendations is a standard way that the reviewer will indicate areas for improvement that they feel need to be addressed. The SAR in Rapid Time model uses ‘questions for the board’ in place of recommendations as a vehicle for engaging the board members in considering the areas for improvement necessary. Reaction to this format was mixed. Most found it useful to some extent, but participants tended to feel it ‘left them short’. ‘I want to be told what the must dos are and what would be beneficial to consider’ (SAB 7).

Developing an action plan

This is a further phase after the completion of the report which is led and owned by the board and local partners. It is not usual for case reviewers to lead on the development of an action plan, whatever methodology is used.