Safeguarding Documentation Audit

This project audits whether safeguarding documentation is clear, timely, proportionate and actionable. It reviews whether concerns are recognised and described, whether immediate risk and safety actions are recorded, whether the adult or child pathway is identified according to local policy, whether consent, capacity and best-interests considerations are documented, whether advice, referral, route and timing are recorded, and whether communication, handover, incident reporting, follow-up and outcome are documented in the agreed location.

• Doctors, nurses, ACPs and allied health professionals
• Safeguarding leads, named professionals and liaison teams
• Care-home, community, hospice and GP practice clinical leads
• Mental health, learning disability and rehabilitation teams
• QI leads, governance and patient safety teams, supervisors and educators

• Measure whether safeguarding concerns are recognised and documented clearly
• Assess consent, mental capacity and best-interests documentation where information is shared
• Review escalation, referral route, timing and named ownership
• Test communication, interagency contact, handover and follow-up reliability
• Generate governance-ready and ARCP-ready evidence and a re-audit cycle

• Anonymous case identifier
• Inclusion / eligibility decision
• Anonymised context (age band, sex/gender recorded, care setting, safeguarding context)
• Clinical area / location and optional specialty / service
• Twenty-one safeguarding documentation criteria (met / not met / not applicable)
• Free-text learning points and any project custom fields

• Live dashboard
• Audit report (Word)
• Executive summary (Word)
• Excel workbook
• PowerPoint presentation
• Conference poster
• ARCP evidence summary

This ready-built project is developed using the guidance, standards and authoritative sources listed below, so you can see what is being measured and why. Lazomis QI does not publish or own this guidance, and inclusion here does not imply endorsement or approval by any of these organisations.

• NHS England

  Safeguarding children, young people and adults at risk in the NHS: Safeguarding Accountability and Assurance Framework(opens the original source in a new tab)

  National framework setting out NHS safeguarding accountability, roles and assurance expectations.

• Department of Health and Social Care

  Care and support statutory guidance (Care Act 2014) — adult safeguarding and section 42 enquiries(opens the original source in a new tab)

  Statutory guidance on adult safeguarding duties, enquiries and making safeguarding personal.

• Department for Education

  Working Together to Safeguard Children (2023)(opens the original source in a new tab)

  Statutory guidance on multi-agency working to safeguard and promote the welfare of children.

• Legislation

  Mental Capacity Act 2005(opens the original source in a new tab)

  Statutory framework for capacity assessment, best-interests decisions and information sharing where capacity is in question.

• Legislation

  Children Act 1989 and Children Act 2004(opens the original source in a new tab)

  Statutory framework where child safeguarding duties are in scope for the project.

• Local policy

  Local safeguarding adults and children procedures, referral pathways and escalation routes

  Local Safeguarding Adults Board and Safeguarding Children Partnership procedures, domestic abuse, Prevent, modern slavery, self-neglect, MCA / DoLS, information-sharing, supervision, incident reporting and EPR documentation policy define thresholds, routes, forms and out-of-hours arrangements. Confirm local policy before setting targets.

• Designed to use anonymised or pseudonymised audit identifiers.
• This tool supports, but does not replace, clinical judgement.
• Local policy, formulary and specialist advice should be followed.
• Organisations remain responsible for local governance arrangements.
• This tool supports documentation review only. It does not replace safeguarding advice, local safeguarding policy, specialist safeguarding teams, statutory duties, emergency escalation or clinical judgement.
• Referral thresholds, referral routes, named teams, forms and out-of-hours arrangements are locally configured and are not presented here as national standards.
• Use anonymous case identifiers only — never patient-identifiable information, and never identifiable detail about family members, alleged perpetrators or staff.

Supporting guidance from the Lazomis QI Resource Library. Authoritative clinical standards referenced by this project remain separate.

• Clinical GovernanceLeveraging Incident Themes for Quality Improvement and Patient SafetyThis guide helps NHS teams identify and analyse recurring incident themes, transforming reported safety events into practical quality improvement opportunities to enhance patient safety and system reliability.
• Patient SafetyEscalation Failures: Understanding and Preventing Harm in Clinical PracticeEscalation failures are a significant contributor to avoidable harm in healthcare. This guide explores their root causes and outlines practical steps for NHS staff to improve communication, clinical handover, and timely senior review.
• Patient SafetyIntegrating Patient Safety and Quality Improvement: A Practical Guide for UK CliniciansThis guide explains the foundational principles of patient safety and quality improvement (QI) within the UK healthcare context, offering practical strategies for clinicians to enhance safety and improve care delivery.
• Clinical GovernanceIntegrating Quality Improvement into Clinical Governance FrameworksThis article explores the vital relationship between Quality Improvement (QI) and Clinical Governance within the NHS, demonstrating how they are two sides of the same coin when aiming for continuous, systematic improvement in patient care.