Governance reminder
Lazomis QI supports quality improvement planning and documentation. It does not replace clinical judgement, statutory safeguarding processes, local policy or organisational governance. Ensure all improvement activity is agreed with the safeguarding committee and implemented in accordance with local requirements.
1. Baseline findings summary
Pulled from dashboard where possible.
2. Key problems identified
3. Root cause / contributory factors
People · Process · Environment · IT · Documentation · Communication · Training · Workload
4. Improvement aim
Specific, measurable, achievable, relevant, time-bound
5. Suggested local improvement actions
Editable — framed as local implementation ideas, not national guidance.
| Action | Linked problem | Owner | Target date | Status |
|---|---|---|---|---|
| Add structured safeguarding documentation template to EPR | Timeliness and completeness of documentation variable | IT & Safeguarding Committee | 8 weeks | Planned |
| Mandatory prompt to escalate to named safeguarding lead | Lead not notified in a timely way | Named Doctor / Named Nurse | 6 weeks | In progress |
| Embed MCA prompt in adult safeguarding EPR template | MCA not documented in adult cases | Adult Safeguarding Lead | 8 weeks | Planned |
| Structured safeguarding huddle at post-take round | MDT discussion inconsistent | Clinical Director | 12 weeks | Not started |
| Ward-level weekly safeguarding documentation feedback | Variation between clinical areas | QI Lead | 4 weeks | In progress |
6. PDSA cycle 1
Plan · Do · Study · Act
7. Intervention log
8. Re-audit plan
9. Sustainability plan
10. Learning points
11. Governance summary
12. ARCP / portfolio evidence summary
Populates the ARCP evidence output.
Improvement themes
Common action areas for safeguarding documentation improvement.
Timely documentation of safeguarding concerns
EPR safeguarding template and mandatory fields
Named safeguarding lead notification pathway
Chronology and factual documentation
Patient / child voice
Body maps and objective physical findings
Household, siblings and dependants
Immediate safety planning
External referral (MASH / adult safeguarding / police)
Mental Capacity Act application (adult)
Making Safeguarding Personal (adult)
Child Protection Plan awareness (child)
Consent and information sharing
MDT / safeguarding huddle documentation
Discharge safety planning
Communication with GP / community / school nurse / health visitor
Outcome documentation and closure
Weekend and out-of-hours documentation
Feedback to clinical teams
Re-audit and sustainability