Using Root Cause Analysis to Strengthen Safeguarding Decision-Making and Thresholds
Safeguarding concerns often emerge gradually, shaped by judgement calls, competing priorities and unclear thresholds rather than single catastrophic failures. When safeguarding incidents are investigated in isolation, providers risk missing deeper system weaknesses around decision-making, escalation and professional confidence. Applying root cause analysis within established quality standards and frameworks allows providers to understand why safeguarding decisions were made, how thresholds were interpreted, and what controls must change to prevent recurrence.
This article explores how RCA can be used to strengthen safeguarding decision-making, improve escalation consistency, and provide defensible governance assurance.
Why Safeguarding RCA Must Focus on Decision-Making
In many safeguarding RCAs, the factual timeline is clear but the rationale behind decisions is not. Providers may know what happened, but not why staff did or did not escalate concerns at specific points.
Effective safeguarding RCA therefore examines:
- How risk was perceived at the time (not retrospectively)
- What guidance or thresholds staff relied upon
- How confident staff felt to escalate or challenge
- Whether supervision and management oversight supported safe judgement
Operational Example 1: Gradual Deterioration Not Escalated
Context: A safeguarding concern arose following a gradual decline in a person’s physical and emotional wellbeing, with multiple low-level indicators recorded over several weeks.
Support approach: RCA reviewed daily notes, health monitoring records, supervision discussions and communication with external professionals.
Day-to-day delivery detail: Staff recorded observations but described them individually rather than cumulatively. Each shift viewed changes as “not significant enough” in isolation. Supervision discussions focused on task completion rather than risk interpretation. There was no prompt to step back and assess patterns over time.
How effectiveness or change is evidenced: The provider introduced a cumulative risk review trigger, requiring managers to review patterns weekly where repeated concerns are logged. Staff were trained to summarise change over time, not just daily events. Evidence included clearer escalation rationales, earlier safeguarding referrals, and reduced recurrence of “missed pattern” themes in RCAs.
Strengthening Safeguarding Thresholds Through RCA
RCAs often reveal that thresholds are understood differently across teams. Some staff escalate early; others wait for certainty. While professional judgement is essential, unmanaged variation increases risk.
Providers should use RCA findings to:
- Clarify what “early help” versus safeguarding looks like in practice
- Define non-negotiable escalation triggers
- Provide examples of cumulative harm indicators
- Embed threshold discussion into supervision and team meetings
Operational Example 2: Delay Due to Professional Deference
Context: Staff raised concerns informally with a visiting professional but did not escalate further when no action followed.
Support approach: RCA explored confidence to challenge, clarity of escalation routes, and management response.
Day-to-day delivery detail: Staff assumed that once concerns were mentioned, responsibility transferred to the professional. There was no documented follow-up or timeframe for response. Managers were not alerted because staff believed escalation would be seen as “overreacting”.
How effectiveness or change is evidenced: The provider clarified escalation expectations where external responses are delayed, introduced a “no response follow-up” protocol, and reinforced that safeguarding responsibility remains with the provider. Evidence included clearer records of professional challenge, time-bound follow-ups, and stronger safeguarding chronology.
Commissioner Expectation
Commissioner expectation: Commissioners expect providers to demonstrate consistent safeguarding thresholds, timely escalation, and clear decision-making rationale. They look for evidence that learning from safeguarding incidents improves staff confidence, reduces variation, and strengthens early intervention.
Regulator / Inspector Expectation
Regulator / Inspector expectation (CQC): Inspectors expect safeguarding systems to be proactive, not reactive. They assess whether providers identify risk early, escalate appropriately, and learn from safeguarding incidents to improve practice and oversight.
Operational Example 3: Over-Reliance on Informal Management Advice
Context: Staff sought informal reassurance from a manager rather than initiating safeguarding processes.
Support approach: RCA examined supervision records, on-call advice logs and escalation pathways.
Day-to-day delivery detail: Managers provided verbal guidance but did not always record rationale or decisions. Staff interpreted reassurance as confirmation that no safeguarding action was required. There was limited audit trail showing how decisions were reached.
How effectiveness or change is evidenced: The provider introduced mandatory recording of safeguarding advice, with clear decision outcomes and review points. Evidence included improved audit trails, stronger management accountability, and clearer learning from safeguarding RCAs.
Embedding Safeguarding Learning Into Governance
Safeguarding RCA themes should be visible in:
- Safeguarding committee reports
- Risk registers and escalation logs
- Supervision and competency frameworks
- Training priorities and scenario-based learning
When RCA learning reshapes how staff interpret risk and act on concerns, safeguarding systems become safer, clearer and more defensible.