SAR Quality Marker 12: Analysis

SAR Quality Marker 12

The approach and methodology agreed for the SAR is used with optimum rigour within the size and scope of SAR commissioned. Analysis assumes a systems approach to safety and organisational reliability. It is anchored in relevant research and wider evidence base regarding effective clinical/professional practice and that of safety science. It draws on the full range of relevant information and input assembled, to evaluate and explain professional practice in the case(s) or the responses to earlier learning. Conclusions are of practical value, evidencing the wider learning identified about routine barriers and enablers to good practice, systemic risks and/or what has facilitated or obstructed change to date. There is transparency about any methodological limitations and the implications for the comprehensiveness or level of confidence in the analysis and findings.

Questions to consider for:

  1. Are you championing the practical value of analysis that identifies what has led to and sustained the kind of practice problems or good practice that the case(s) reveals?
  2. Are you building expectation at Board level of an analysis that seeks out causal factors and systems learning of relevance beyond the individual case or cases?
  3. Are you managing expectations if the SAR is focused on exploring why progress had not been achieved against earlier learning, rather than a detailed analysis of the case referred for a SAR?

Analysing practice in a case or cases

  1. Is there adequate attention to detail and precision in presentation of the facts of the case and professional practice over the time period, to match the commission?
  2. Has practice in the case been evaluated appropriately, identifying good practice and any shortfalls with reference to up-to-date research and the wider evidence base where this is helpful or necessary?
  3. Does the assessment of practice in the case reflect the principles of Making Safeguarding Personal and the six core adult safeguarding principles?
  4. Does the analysis explain why people did what they did in such a way that even incredible actions or inactions are comprehensible in the context of what people were trying to achieve, the challenges and constraints of their work environment, as well as social and cultural aspects of single, multi-agency and multi-professional working?
  5. Has the analysis of causal factors and efforts to untangle systemic risks been conducted with reference to up-to-date research and wider evidence base on safety science and ‘human factors’ that underpin a ‘systems approach’ to learning from practice and incidents?
  6. Has the analysis clarified whether practice issues were unique to the case(s) and context or emblematic of wider issues and whether the factors that influenced were anomalies or systemic?
  7. Where required in the commission has the analysis detailed the current relevance of past practice issues and their systemic conditions?
  8. Where reference is made to practice beyond the case, either at the time of the case or in the present, is it clear where the knowledge about the wider safeguarding system has come from?
  9. Does the analysis have clear conclusions and show clearly how the conclusions relate to the case(s), as well as why they are relevant to wider safeguarding practice?

Progressing improvement activity

  1. Does the analysis identify and evidence what has or has not changed in relation to earlier learning?
  2. Is there a causal analysis of what facilitated or obstructed progress?

Rigour and reliability of analysis

  1. Is there adequate detail and precision in the analysis relative to the size and scope of the SAR commissioned?
  2. Is up-to-date research and the wider evidence-base about what constitutes good practice, being used in the analysis?
  3. Is the causal analysis informed by, and referenced where appropriate, the evidence-base of safety science and human factors?
  4. Is it clear what specific techniques have been used to minimise the bias of hindsight and knowledge of the outcome, on the analysis?
  5. Does the presentation of the analysis show the working-out process adequately, allowing the interpretation to be critiqued and counter evidence to be brought to bear?
  6. Does the lead reviewer(s) access supervision or peer challenge to support the quality of analysis undertaken?

  1. Are the principles of Making Safeguarding Personal and the six core safeguarding principles reflected in your evaluation of safeguarding practice in the case(s)?
  2. Are you sustaining a determined curiosity to take your analysis beyond commenting on compliance with relevant procedures, to providing explanations of professional behaviour that call on a range of social/cultural and organisational factors?
  3. What approaches have you used to ward against only a partial use of information and input assembled for this SAR?
  4. Is your analysis moving from the specific to the generalizable, identifying what professional activity in the case(s) reveals about how service delivery routinely worked at the time and why, and clarifying the nature of systemic risks that remain today?
  5. In your analysis, are you balancing practice expertise with expertise in human factors and safety science to support a rigorous interrogation of causal factors?
  6. Have you considered the full range of research evidence, practice knowledge, guidance and theory, statute, national policy, other SARs and inspection reports that might be referenced in order to articulate the underpinning knowledge base relevant to your analysis?

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