Root Cause Analysis in Adult Social Care: Practical Investigations that Change Practice
Root cause analysis (RCA) is often associated with serious incidents, but its real value is in preventing repeat harm by strengthening controls and practice. A provider’s learning, incidents and continuous improvement approach should set out when RCA is used and how learning is applied, while strong governance and leadership ensures investigations are credible, proportionate and lead to sustained change.
This article sets out how to do RCA in a practical, defensible way that supports managers and stands up to commissioner and CQC scrutiny.
When to use RCA and when not to
Not every incident needs a full RCA. A proportionate model helps avoid wasting time while missing patterns. RCA is usually appropriate when:
- There is serious harm, near-fatal harm or high safeguarding risk
- There are repeat incidents with the same theme (e.g., repeated falls)
- A system failure is suspected (handover, staffing, medicines process)
- There is regulatory or commissioner concern about service safety
For low-risk incidents, a concise “manager review” can be sufficient, provided learning is still captured.
What commissioners and inspectors expect from an investigation
Investigations must be more than narrative. A defensible RCA shows:
- What happened: clear chronology and immediate actions.
- Why it happened: contributory factors, not just “human error”.
- What changed: corrective and preventive actions, linked to controls.
- How you know it worked: monitoring, re-checks, trend reduction.
RCA should be written in plain English with evidence referenced (notes, rotas, training records, observations, interviews).
Build the timeline first: get the facts right
A weak timeline produces weak conclusions. A practical approach is:
- Compile a chronology from records (daily notes, MARs, call logs, incident forms)
- Confirm with staff interviews (what they saw, what they decided, why)
- Check for “hidden” evidence (handover notes, on-call records, family contact logs)
Leaders should be able to defend the timeline if challenged by commissioners, safeguarding teams or inspectors.
Identify contributory factors across the system
RCA should explore multiple factor categories. In adult social care these commonly include:
- People factors: competency, supervision, fatigue, confidence
- Process factors: unclear steps, gaps in escalation routes, documentation issues
- Environment factors: layout risks, lighting, equipment availability
- Communication factors: handover quality, family communication, multi-agency contact
- Leadership factors: staffing decisions, audit follow-through, clarity of expectations
A useful test is: if you removed one factor, would the incident still have happened? If yes, keep looking.
Operational example 1: Repeated falls linked to care plan drift
Context: A person experiences multiple falls after a period of stability. The service has incident forms but no reduction in falls.
Support approach: The manager triggers RCA because the theme is repeating and harm risk is increasing.
Day-to-day delivery detail: The investigation timeline shows that the person’s mobility deteriorated, but care plans were not updated quickly and staff continued using previous transfer prompts. Interviews reveal staff were unsure who was responsible for updating the mobility risk assessment after GP advice. Controls are strengthened: a clear responsibility for updating risk assessments within 24 hours of clinical changes, and an on-shift briefing requirement for high-risk mobility updates.
How effectiveness or change is evidenced: A re-check confirms updated care plans, staff supervision records show competency reinforcement, and falls frequency reduces over the next six weeks.
Operational example 2: Medication error caused by weekend handover failure
Context: A medication omission occurs in a supported living service on a weekend, with inconsistent explanations from staff.
Support approach: The RCA focuses on system controls: handover, MAR management, on-call support, and supervision.
Day-to-day delivery detail: The timeline reveals that the regular key worker was off, agency staff attended, and the weekend handover was verbal only. The MAR was incomplete, and staff were reluctant to call on-call for clarification. Actions include a structured weekend handover template, a “call on-call” expectation for any MAR discrepancy, and a short competency check for agency staff at the start of shift.
How effectiveness or change is evidenced: Subsequent weekend audits show improved handover quality and reduced medication discrepancies, evidenced through spot checks and incident trend data.
Operational example 3: Distress incident highlights gaps in positive risk-taking
Context: A person living with dementia becomes distressed when prevented from leaving the building, resulting in an injury during staff intervention.
Support approach: The RCA is framed around both safety and rights, including restrictive practice governance and de-escalation practice.
Day-to-day delivery detail: The investigation finds staff defaulted to physical blocking because there was no agreed plan for supported outdoor access and no shared understanding of triggers. The control change includes a proactive routine, safe outdoor access planning, and refresher training on de-escalation. It also includes a review of whether any restrictions are lawful and documented, with family and professional involvement.
How effectiveness or change is evidenced: The provider tracks distress incidents, observes staff using new de-escalation approaches, and documents improved wellbeing indicators and reduced restrictive responses.
Commissioner expectation
Commissioner expectation: Commissioners expect investigations to be timely, evidence-based and linked to service improvement. They look for clear accountability, action completion and evidence that repeat incidents reduce after controls are strengthened.
Regulator / Inspector expectation
Regulator / Inspector expectation (CQC): CQC expects providers to investigate incidents, identify causes and take action to prevent recurrence. Inspectors will test whether leaders understand themes, whether actions were implemented, and whether improvement is sustained.
Turn findings into controls, not just recommendations
RCA outputs should translate into practical controls: updated processes, clearer roles, competency reinforcement, supervision themes, and monitoring. The final step is re-testing: checking whether the change is embedded and whether incident rates improve. That is the difference between an investigation and a learning system.