Using Root Cause Analysis to Strengthen Safeguarding and Risk Management
Safeguarding incidents represent some of the highest-risk events within adult social care, both in terms of individual harm and organisational accountability. Root Cause Analysis (RCA) provides a structured method for understanding why safeguarding failures occur and how systems, practice and oversight must change to reduce future risk. When aligned with root cause analysis methodologies and established quality standards and frameworks, RCA becomes a cornerstone of safeguarding governance.
This article examines how RCA supports safeguarding assurance, focusing on operational practice, governance expectations and regulator scrutiny.
The Role of RCA in Safeguarding Systems
Safeguarding failures rarely result from a single error. They typically emerge from cumulative weaknesses such as unclear thresholds, inconsistent supervision, training gaps or ineffective escalation. RCA enables providers to move beyond immediate triggers and examine contributory factors across systems and behaviours.
Effective safeguarding RCA considers decision-making, communication, workforce capability and leadership oversight alongside frontline practice.
Operational Example 1: Failure to Escalate Safeguarding Concerns
Context: Early indicators of neglect were identified but not escalated, resulting in harm.
Support approach: RCA reviewed staff decision-making, safeguarding thresholds and supervision processes.
Day-to-day detail: Staff reported uncertainty about escalation criteria and inconsistent guidance during supervision.
Evidence of effectiveness: Revised safeguarding thresholds, scenario-based training and strengthened supervision audits reduced delayed escalations.
Integrating RCA With Risk Management
Safeguarding RCA should link directly to organisational risk registers. Where repeated themes emerge, providers must evidence how risks are escalated, mitigated and monitored at senior level.
This integration ensures safeguarding learning informs broader risk management rather than remaining reactive.
Operational Example 2: Financial Abuse by External Parties
Context: A service user experienced repeated financial exploitation.
Support approach: RCA examined safeguarding plans, community access arrangements and staff awareness.
Day-to-day detail: Weak monitoring arrangements and limited staff confidence in challenging third parties were identified.
Evidence of effectiveness: Enhanced financial safeguarding training and revised risk assessments reduced recurrence.
Commissioner Expectation
Commissioner expectation: Commissioners expect safeguarding RCA to demonstrate learning beyond the individual case, including workforce development, service redesign and improved risk controls.
Regulator Expectation
Regulator expectation (CQC): Inspectors expect providers to show how safeguarding incidents inform safer systems, clearer decision-making and stronger leadership oversight.
Operational Example 3: Restrictive Practice Without Proper Authorisation
Context: Restrictive practices were used without appropriate authorisation or review.
Support approach: RCA reviewed staff training, documentation and management oversight.
Day-to-day detail: Gaps were identified in MCA knowledge and recording standards.
Evidence of effectiveness: Targeted MCA training and revised authorisation processes improved compliance and oversight.
Building Safeguarding Assurance Through RCA
RCA strengthens safeguarding when learning is embedded through training, supervision, audit and governance reporting. Providers that use RCA consistently demonstrate maturity, accountability and a proactive safeguarding culture.