Conducting Effective Incident Investigations in Adult Social Care: From Facts to Root Causes
When an incident occurs, the quality of the investigation often determines whether the service improves or repeats the same risk in a different form. In a mature learning, incidents and continuous improvement culture, investigations are structured, proportionate and focused on what needs to change in day-to-day practice. Strong governance and leadership ensures investigations are independent enough to be credible, and rigorous enough to withstand commissioner challenge and CQC inspection.
This article sets out a practical investigation model for adult social care providers, showing how to move from basic fact-finding to root cause analysis, proportionate actions and measurable impact.
What “good” looks like: investigation outcomes that stand up to scrutiny
A defensible investigation should produce four things:
- Clarity: a reliable account of what happened, when and who was involved
- Understanding: why it happened, including system and human factors
- Control: actions that reduce the likelihood of recurrence
- Evidence: proof that actions were implemented and monitored
Investigations that stop at “staff retrained” or “reminded of policy” rarely prevent recurrence unless the underlying conditions are also addressed.
Setting the scope: proportionate and timely
Not every incident needs a full root cause analysis, but every incident needs an appropriate level of investigation. A simple scoping decision should consider:
- Actual or potential harm
- Safeguarding or regulatory thresholds
- Repetition of similar incidents
- Complexity (multiple agencies, multiple staff, unclear facts)
Operationally, scoping should be recorded (for example, on an investigation header sheet) so the rationale is visible during audits and inspections.
Evidence gathering that is operationally credible
Providers should treat investigations like assurance work. Evidence typically includes:
- Care plans, risk assessments and daily records
- MAR charts / medication logs (where relevant)
- Rotas, staffing levels and supervision records
- Training and competency records
- Environmental checks (where relevant)
- Statements from staff and, where appropriate, the person supported and family
The key is triangulation: evidence should corroborate the timeline, not just repeat recollections.
Operational example 1: Falls investigation identifies system drift
Context: A resident experiences two falls in one week, one resulting in hospital admission.
Support approach: The manager scopes a formal investigation due to harm and repeat events.
Day-to-day delivery detail: The timeline shows both falls occurred during transfers after toileting. Care plans show the resident needs two staff support, but rotas show only one staff member was consistently available during that time due to breaks. Supervision notes show recent reminders about two-person support were not reinforced with observation. The service introduces protected staffing during peak transfer periods, records two-person transfer observations weekly for four weeks, and updates the risk assessment to reflect “high-risk window” times.
How effectiveness or change is evidenced: Observation records show compliance, incident rates reduce, and governance minutes record rota changes as a control with a review date.
Root cause analysis that goes beyond “human error”
Root cause analysis in social care should test both individual and system factors. Common lines of enquiry include:
- Was the care plan clear, current and usable?
- Were staff trained and competent for the task?
- Was supervision effective and recent?
- Did staffing levels and skill mix support safe delivery?
- Were environmental or routine pressures influencing decisions?
- Were restrictive practices or risk-taking decisions understood and documented?
Operational example 2: Medication incident exposes assurance gaps
Context: A missed dose occurs for a high-risk medicine in a domiciliary setting.
Support approach: The provider investigates beyond the immediate missed administration.
Day-to-day delivery detail: Records show the medicine was present, but the staff member was unfamiliar with the packaging and did not escalate. Training records show medication training was completed, but competency reassessment is overdue. The investigation also finds spot-checks are being completed but not sampling high-risk medicines. Actions include competency reassessment, updating the MAR guidance with photos for common high-risk medicines, and revising audit sampling rules to prioritise high-risk items.
How effectiveness or change is evidenced: Competencies are logged, audits demonstrate the new sampling approach, and the provider can show reduced medication-related near misses over the next quarter.
Operational example 3: Behaviour incident reveals restrictive practice risk
Context: A supported living tenant becomes distressed and staff use an informal “door blocking” approach to prevent leaving.
Support approach: The investigation considers safeguarding, restrictive practice and mental capacity implications.
Day-to-day delivery detail: Evidence shows staff believed they were preventing harm, but there was no documented best-interests decision, no escalation plan, and the Positive Behaviour Support plan lacked clear guidance on least restrictive options. Actions include an urgent care review, refresher training on restrictive practices and escalation, and implementing a manager check that any restriction is documented, time-limited and reviewed within 24 hours.
How effectiveness or change is evidenced: Subsequent incidents are managed through de-escalation and agreed support strategies, and governance logs show restrictive practice monitoring with review outcomes.
Commissioner expectation
Commissioner expectation: Commissioners expect providers to investigate incidents proportionately, identify root causes, and implement actions that reduce repeat harm. They will look for audit trails, action tracking and evidence of learning at governance level.
Regulator / Inspector expectation
Regulator / Inspector expectation (CQC): CQC expects incidents to be investigated thoroughly and used to improve safety. Inspectors assess whether leaders are open, understand contributory factors, and can evidence sustained improvement rather than one-off fixes.
Turning investigations into improvement: action tracking and assurance
Actions should be specific, time-bound and assigned to named owners. Good practice includes an action tracker reviewed at service and senior governance meetings, with clear evidence of completion and impact measures (for example, repeat incident reduction, supervision compliance, audit results, or improved care plan quality).