28
Managing falls and fractures in care homes for older people Falls Prevention and Management Resource Pack Falls Prevention Service Wilson Hospital Cranmer Road, Mitcham CR4 4TP Tel: 020 8254 8247 Fax: 020 3458 5528

Falls Prevention and Management Resource Pack Falls... · Falls Prevention and Management Resource Pack ... the Care Inspectorate. The full resource can be ... buzzer – electrical

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Managing falls and fractures in care homes for older people

Falls Prevention and ManagementResource Pack

Falls Prevention ServiceWilson HospitalCranmer Road, MitchamCR4 4TP

Tel: 020 8254 8247Fax: 020 3458 5528

2

ContentsIntroduction 3

Tools for Staff

1. Care home resident falls and fracture risk/intervention tool 4

2. Resident environment and orientation check 5

Tools for Managers

1. Care homes falls questionnaire 6

2. Care homes multifactorial falls risk assessment and management tool 7

3. Care homes falls prevention monitoring form 14

4. Care homes generic falls environmental risk assessment form 16

5. Care homes monthly falls overview form 20

6. Care homes post fall/incident report form 21

Additional information

Annex A – Care homes post fall pathway 25

Annex B – Care homes had a fall poster 26

Annex C – Medicines associated with falls 27

3

IntroductionWhat is this resource pack about?This resource pack provides the answers to many of the questions care home managers have in relation to the prevention and management of falls and fractures and can act as an excellent educational tool for new or existing care home staff.

“Managing falls and fractures in care homes for older people” provides the direction, advice and support that staff in a care home need to make a difference in this area of care. The resource which is research-based not only gives the guidance required, but offers tools which can be used in a care home to help improve or change practice.

Why should I use it?Falls are an inevitable part of ageing. In many cases, taking the right steps at the right time can prevent falls and enable an older person to continue a physically active life. Care home staff have a key role to play in falls prevention, but they need to have knowledge and understanding.

Older people living in care homes are three times more likely to fall than older people living in their own homes, with the result of a fall often being much more serious; there are ten times more hip fractures in care homes than in other environments. Many factors can contribute to this heightened risk, such as physical frailty, the presence of long term conditions, physical inactivity, taking multiple medications and the unfamiliarity of new surroundings. For this reason, it is important that all care homes for older people implement a person centred process to manage and reduce falls and fractures. This will help to improve the overall quality of care for an individual and will have a huge impact on a person’s independence and participation in life.

How should I use it?The resources are split into groups to make them easier to navigate.

There is a section for all staff to use to ensure the home environment and people living in it are safe and risk is minimised and managed where falls are inevitable.

There is a section for managers to monitor falls in the home and develop more proactive management plans for reducing the incidence of falls.

This resource pack has been adapted from the ‘Managing falls and fractures’ Resource Pack as developed by, and with kind permission of, the Care Inspectorate. The full resource can be downloaded at: www.careinspectorate.com

4

Inst

ruct

ions

fo

r us

e: re

fer

to e

ach

area

of r

isk

in tu

rn. C

onsi

der

the

sugg

este

d ac

tions

to h

elp

writ

e a

pers

onal

ised

act

ion

plan

for

a re

side

nt.

Ada

pted

from

a to

ol d

evel

oped

by

Lynn

Fla

nnig

an, N

HS

Lan

arks

hire

Mo

bili

ty/

Bal

ance

Co

nfus

ion/

cog

nitiv

eim

pai

rmen

tF

alls

hi

sto

ryM

edic

atio

nC

ont

inen

ceFo

othe

alth

an

d

foot

wea

r

Diz

zine

ss/

bla

cko

uts

Vis

ion/

hear

ing

Is th

e re

side

nt

unst

eady

or

have

mob

il-ity

pro

b-le

ms?

Doe

s th

e re

side

nt

they

hav

e a

fear

of

fallin

g?

Is th

e re

side

nt

cogn

itive

ly

impa

ired?

Is th

e re

side

nt

mor

e co

nfus

ed

than

nor

mal

?

Co

nsid

er?

• M

ovin

g &

ha

ndlin

g as

sess

-m

ent.

• S

uper

visi

on p

lan.

Enc

oura

ging

saf

e ac

tivity

with

use

of

app

rop.

wal

king

ai

ds.

• R

efer

ral t

o ph

ysio

.•

Ass

essm

ent f

or

hip

prot

ecto

rs.

• M

onito

ring

alco

hol i

ntak

e.

Co

nsid

er?

• C

urre

nt h

ealth

eg

pain

, de

hydr

atio

n,

cons

tipat

ion.

• R

ulin

g ou

t in

fect

ion/

delir

ium

.•

See

king

adv

ice

from

GP

/CP

N.

Opt

imis

ing

envi

ronm

enta

l sa

fety

.•

Tel

ehea

lthca

re•

Pro

mot

ing

safe

ex

erci

se a

nd a

ctiv

-ity

.•

Ass

essm

ent f

or

hip

prot

ecto

rs.

Co

nsid

er?

• P

re-a

dmis

sion

st

rate

gies

.•

Sup

ervi

sion

pla

n,

usin

g •

Wal

king

aid

s w

here

requ

ired.

Enc

oura

ging

saf

e ac

tivity

.•

Ref

erra

l for

fur-

ther

ass

essm

ent e

g ph

ysio

, GP

or

falls

se

rvic

e, if

hig

h ris

k,

unex

plai

ned

falls

or

seve

ral r

ecen

t fal

ls.

• A

sses

sing

for

hip

prot

ecto

rs.

Co

nsid

er?

• A

skin

g ab

out

and

obse

rvin

g fo

r sy

mpt

oms

of

dizz

ines

s/

drow

sine

ss.

• C

heck

ing

BP

(ly

ing/

stan

ding

).•

Med

icat

ion

revi

ew b

y G

P.•

CP

N re

view

.

Co

nsid

er?

• C

heck

ing

for

infe

ctio

n.

• T

oile

ting

regi

me.

Pos

ition

ing

near

to

ilet.

• R

efer

ral t

oD

N o

r co

ntin

ence

se

rvic

e.•

App

ropr

iate

cl

othi

ng.

• A

com

mod

e or

ur

inal

.•

Usi

ng n

ight

lig

hts.

Co

nsid

er?

• D

iscu

ssin

g w

ith

resi

dent

and

fam

ily

suita

ble

foot

wea

r. •

Intr

oduc

ing

a fo

otca

re re

gim

e.

• R

efer

ral t

o po

diat

ry.

Co

nsid

er?

• G

P re

view

, in

clud

ing

med

icat

ion

revi

ew.

• C

heck

ing

lyin

g/st

andi

ng B

P.•

Ref

erra

l to

Falls

C

linic

.

Co

nsid

er?

• E

nsur

ing

glas

ses

and

hear

ing

aids

in

plac

e an

d in

goo

d st

ate

of re

pair.

• E

nsur

ing

good

lig

htin

g.•

Che

ck fo

rea

r w

ax.

• R

efer

ral t

o op

ticia

n/au

diol

ogy.

Hav

e th

ere

been

pr

evio

us

falls

? If

so,

how

man

y;

wha

t wer

e th

e ca

uses

&

con

se-

quen

ces?

Is th

e re

side

nt

taki

ng

beno

dia-

zepi

nes,

ps

ycho

trop

ics

4 or

mor

e m

eds;

or

any

othe

r hi

gh

risk

drug

s?

Are

ther

e an

y co

ntin

ence

is

sues

: in

cont

i-ne

nce,

fre

quen

cy o

r ur

genc

y?

Is

foot

wea

r su

itabl

e?

Are

ther

e fo

ot h

ealth

pr

oble

ms?

Doe

s th

ere

side

nt

appe

ar

dizz

y or

hav

e fa

intin

g at

tack

s?

Doe

s th

ere

side

nt

have

im

paire

d he

arin

g or

sig

ht?

Env

ironm

ent

Po

or

nutr

itio

nB

one

he

alth

Co

nsid

er?

• O

rient

atin

g re

side

nt to

en

viro

nmen

t.•

Usi

ng th

e‘E

nviro

nmen

t A

sses

smen

t too

l’.

• A

ids,

app

lianc

es

and/

or s

igna

ge.

Co

nsid

er?

• R

efer

ral t

o G

P o

r di

etic

ian.

• S

tart

ing

a fo

od

reco

rd c

hart

(as

advi

sed

by G

P o

r di

etic

ian)

.•

Foo

d su

pple

men

ts.

(as

advi

sed

by G

P

or d

ietic

ian)

.•

Enc

oura

ging

go

od fl

uid

inta

ke.

Co

nsid

er?

• T

akin

g os

teop

o-ro

sis

med

icat

ions

an

d/or

cal

cium

and

vi

tam

in D

as

pres

crib

ed.

• D

iscu

ssin

g bo

ne

heal

th w

ith G

P.•

Life

styl

e ad

vice

eg

cal

cium

ric

h di

et, s

afe

sunl

ight

ex

posu

re, s

ensi

ble

alco

hol i

ntak

e,

smok

ing

cess

atio

n,

wei

ght-

bear

ing

activ

ity.

Is th

ere

side

nt

unde

rwei

ght

or h

ave

poor

food

in

take

?

Doe

s th

e re

side

nt

have

os

teop

oros

is

or a

re th

ere

oste

opor

osis

ris

k fa

ctor

s?

Is th

een

viro

nmen

t sa

fe a

ndsu

itabl

e?

If s

till a

pro

ble

m -

co

nsid

er r

efer

ral t

o f

alls

clin

ic

Ris

k fa

cto

rs id

entifi

edD

ate

and

initi

als

Act

ion

pla

nD

ate

and

initi

als

Car

e ho

me

resi

dent

falls

and

frac

ture

ris

k/in

terv

entio

n to

ol

Als

o kn

own

as T

ool 6

: Car

e ho

me

resi

dent

falls

and

frac

ture

risk

/inte

rven

tion

tool

Uni

que

iden

tific

atio

n no

: NR

527a

Ver

sion

no:

1

Janu

ary

2015

Tools for Staff – 1. Care home resident falls and fracture risk/intervention tool

Sample

5

Fo

otw

ear/

clo

thin

g

Wal

king

A

id/

whe

elch

air

Flo

ori

ngLi

ght

ing

Bat

hro

om

Sur

roun

ding

area

Fur

nitu

reB

ed

Is fo

otw

ear

light

wei

ght

and

non-

slip

? A

re

clot

hes

non-

slip

an

d co

rrec

t le

ngth

?

Do

they

re

quire

a

wal

king

ai

d? Is

thei

r w

alki

ng a

id/

whe

elch

air

clea

n an

d in

a

good

sta

te o

f

re

pair?

Co

nsid

er?

• L

iais

ing

with

ne

xt o

f kin

and

di

scus

sing

with

re

side

nt th

e im

port

ance

of

suita

ble

foot

wea

r an

d cl

othi

ng.

• C

heck

ing

foot

wea

r m

onth

ly.•

Pro

visi

on o

f eq

uipm

ent e

g lo

ng

hand

led

shoe

horn

, he

lpin

g ha

nd if

re

quire

d.

Co

nsid

er?

• R

efer

ral t

o lo

cal

phys

io

depa

rtm

ent.

Che

ckin

g co

nditi

on o

f w

alki

ng a

id,

repl

ace

ferr

ules

if

requ

ired.

• C

heck

ing

cond

ition

of

whe

elch

air,

arra

nge

whe

elch

air

repa

ir if

requ

ired.

• If

lap

belts

are

be

ing

used

ap

prop

riate

ly.

Co

nsid

er?

• R

epor

ting

and

reco

rdin

g an

y pr

oble

ms.

• R

earr

angi

ng

furn

iture

if

requ

ired.

Enc

oura

ging

go

od

hous

ekee

ping

.

Co

nsid

er?

• N

ight

ligh

t.•

Bed

side

ligh

t.•

Acc

essi

bilit

y to

re

side

nt.

• A

dditi

onal

lig

htin

g if

requ

ired.

• T

imer

ligh

ting

if re

quire

d.

Co

nsid

er?

• P

ositi

on o

f bu

zzer

. •

Pos

ition

of

soap

/han

d to

wel

s.

• U

sing

a r

aise

d to

ilet s

eat/

toile

t fra

me.

Is th

ere

spac

e fo

r w

alki

ng a

id/

mov

ing

and

hand

ling

equi

pmen

t?

• S

igna

ge.

• G

rabr

ails

.•

Lig

htw

eigh

t do

or.

• C

ontr

astin

g co

lour

s.•

Pos

ition

of b

ed.

Co

nsid

er?

• A

dditi

onal

lig

htin

g.•

Add

ition

al

sign

age.

• F

loor

s di

ffere

nt

colo

ur fr

om w

alls

. •

Ade

quat

e ha

ndra

ils.

• C

lutt

er fr

ee.

• R

epor

ting

and

reco

rdin

g an

y is

sues

.

Co

nsid

er?

• R

earr

angi

ngfu

rnitu

re.

• R

emov

ing

unne

cess

ary

furn

iture

. •

Are

foot

stoo

ls

able

to b

e m

oved

an

d st

ored

saf

ely?

• A

cces

sibi

lity

to:

buz

zer

ele

ctric

al

equ

ipm

ent

war

drob

es

a

nd d

raw

ers.

Co

nsid

er?

• H

eigh

t.•

Mat

tres

s su

itabi

lity.

• P

ositi

on in

ro

om.

• A

cces

sibi

lity

and

abilit

y to

use

bu

zzer

.•

Gra

b ra

ils.

• N

eed

for

bed

rails

.

Is th

e flo

or-

ing

in g

ood

cond

ition

and

no

n-sl

ip?

Are

al

l thr

esho

lds

flush

? Is

th

ere

ade

quat

e sp

ace,

fr

ee fr

om

c

lutt

er?

Is th

e lig

htin

g su

itabl

e fo

r th

e re

side

nt’s

ne

eds?

Is th

e ba

thro

om

suita

ble

for

the

resi

dent

/st

aff n

eeds

? C

an th

e re

side

nt fi

nd

it ea

sily

?

Are

the

hallw

ays

wel

l lit

and

wel

l sig

n-

post

ed fo

r re

side

nt?

Is

ther

e ea

sy

acce

ss?

Is th

ere

adeq

uate

sp

ace

for

wal

king

aid

/m

ovin

g an

d ha

ndlin

g eq

uipm

ent?

Is th

e be

d su

itabl

e fo

r re

side

nt’s

ne

eds?

This

tool

can

be

used

as

a pr

ompt

to c

onsi

der

envi

ronm

enta

l ris

ks re

latin

g to

the

indi

vidu

al a

nd th

eir

own

room

Ada

pted

from

a to

ol d

evel

oped

by

Lynn

Fla

nnig

an, N

HS

Lan

arks

hire

Res

iden

t env

iron

men

t and

ori

enta

tion

chec

k

Als

o kn

own

as T

ool 4

: Res

iden

t env

ironm

ent a

nd o

rient

atio

n ch

eck

Ver

sion

no:

1

Janu

ary

2015

Uni

que

iden

tific

atio

n no

: NR

527b

Tools for Staff – 2. Resident environment and orientation check

Sample

6

Tools for Managers – 1. Care homes falls questionnaire

Resident’s name:

Please take a few moments to complete the following questions. Once completed please return it to a member of staff who will discuss it with you to develop a care plan suited to your needs.

1. How many falls have you had in the past 12 months?

2. If so, where were you when you fell and what were you doing at the time?

3. Have you had any injuries due to a fall?

4. Do you use any of the following to help keep you safe?

Walking aid Raised toilet seat Bed rails

Sensor mats Hospital bed Manual wheelchair

Electric wheelchair

This is completed by the individual or principal carer as part of the pre-admission assessment.

Adapted from a questionnaire developed by Lynn Flannigan, Linda Laffery, Denise Stewart and colleagues in Lanarkshire.

Falls Questionnaire

Also known as Tool 3: Falls Questionnaire

Version no: 1 January 2015

Unique identification no: NR527c

Sample

7

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Name of resident:

DOB: Room no.:

Name of assessor:

Date of assessment:

Record all risks and actions in the resident’s care plan.

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

1. History of falling:Has the resident had one or more falls in the past 12 months?

a. Obtain details about past falls, including how many, causes, activity at time of fall, injuries, symptoms such as dizziness, and previous treatment received. Determine any patterns and consider throughout assessment. Ask about/observe for fear of falling.

b. Discuss falls risk with family.c. Flag in care plan and at handover if

resident is high falls risk.

Consider:d. Contacting GP or falls prevention

services to review resident’s falls risks if at high risk or there have been unexplained falls or several falls in a short period of time. Give details of specific concerns.

e. If recent falls, and the resident has a temperature (fever), consider checking for infection (with urine, sputum and stool samples).

f. Assess for postural or orthostatic hypotension (a drop in BP when standing up). Record in resident’s progress notes and inform GP if hypotension found.

g. Consider how the resident can be observed/supervised more easily.

1/7

Sample

8

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

2. Balance and mobility:Is the resident unsteady/unsafe walking?

Does the resident have difficulty with transfers (getting on and off the toilet/bed/chair)?

a. Ensure mobility aid and rails are used correctly and consistently. Prompt, place within reach, and use visual cues if appropriate. (Seek advice if unsure of correct use of mobility aids).

b. Provide supervision when walking or transferring if required. Record what assistance is required.

c. Record and hand-over recommendations from physiotherapist regarding mobility and transfer status (eg if supervision is needed)

d. Review bathroom grab rails. Are they appropriate and in good condition? Refer to maintenance if necessary.

e. Ensure brakes are on bed at all times. Ensure correct height of bed and chairs.

f. Ensure that frequently used items are within easy reach ie glasses, drinks, walking aid.

g. Ensure buzzer is within easy reach and the resident is able to use it.

h. Ensure residents with poor mobility, who are known not to ask for assistance, are not left unattended on commodes, toilets, baths and showers (consider/discuss the balance between safety and dignity).

i. Increase opportunity for appropriate exercise through Activities of Daily Living (ADL) and the activities programme.

Consider:j. If required, discuss concerns with the GP or

physiotherapist to identify need for assessment of balance, walking and transfers, assessment for/review of mobility aid. Record concerns in the resident’s notes.

k. Hip protectors - discuss suitability and funding with resident’s care manager and family.

3. Osteoporosis:Does the resident have osteoporosis (check transfer notes or ask GP)

If not:Is the resident at risk of osteoporosis?

Ask the following: • Has he/she had fracture

after a minor bump or fall, over the age of 50?

• Is there a family history of osteoporosis or hip fracture?

• Has he/she been on steroids for 3 months or more?

• Is there loss of height and an outward curve of the spine?

a. If osteoporosis is diagnosed check the resident is taking medication for osteoporosis as prescribed.

b. If at high risk speak to GP about osteoporosis risk and further investigation and/or treatment.

2/7

Sample

9

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

4. Medication:Is the resident taking 4 or more medications?

Is the resident taking any of the following?– Sedatives– Anti-depressants– Anti-Parkinson’s – Diuretics (water tablets)– Anti-psychotics– Anti-coagulants– Anti-hypertensives

Has there been a recent change in medication that may effect falls risk (eg changes involving any of the above?)

a. Check medications have been reviewed with respect to falls risk (within the last 12 months is good practice).

b. Report side-effects/symptoms of medication to GP.

c. Read patient information leaflet which comes with the medication or speak to local pharmacist for information on medication side effects and interactions.

d. Anticipate side-effects and take appropriate measures:– Sedatives: toilet and prepare for bed before

giving night sedation. Monitor at all times, but especially overnight and supervise in the morning.

– Anti-psychotics: can cause sedation, postural hypotension and impaired balance. Anticipate and compensate and report to GP.

– Inform GP if the resident is excessively drowsy or mobility has deteriorated.

– Diuretics: anticipate immediate and subsequent toileting. Ensure easy access to toilet and assist if required.

e. Write in progress notes and alert staff at handover.

f. Report changes in alertness or mobility.g. Assess for postural hypotension before and one

hour after morning medications, for 3 days.h. Anticipate side-effects and take appropriate

measures.5. Dizziness and fainting:

Does the resident experience:• dizziness on standing• a sensation of the room spinning when moving their head or body • fainting attacks• palpitations?

a. Carry out a lying standing blood pressure reading to check for postural or orthostatic hypotension if staff trained to do so

b. Refer the resident to the GP for review of dizziness/fainting/blackouts/palpitations.

c. If postural/orthostatic hypotension prompt resident to move ankles up and down before rising, then rise slowly and with care from lying to sitting, and sitting to standing.

6. Nutrition:Has the resident lost weight unintentionally or do they have little appetite?

Does the resident spend little time outside in daylight?

a. Refer to GP or dietician.b. In consultation with GP or dietician: – commence food record chart. – consider food supplements.

Refer to GP for assessment of vitamin D levels.

3/7

Sample

10

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

7. Cognitive impairment:Is the resident confused, disorientated, restless or highly irritable or agitated?

Does the resident have reduced insight and/or judgement and/or are they uncooperative with staff?

a. If there is a new change in cognitive status monitor for pain, signs of infection or constipation.

b. Monitor behavioural issues and discuss chart with GP.

c. Include behavioural issues in care plan and follow with regard to falls prevention.

d. Ensure the resident’s GP has reviewed this condition. Report fluctuations and patterns to treating GP.

e. Do not leave the resident unattended on commodes, in toilets, baths or showers.

f. Optimise environmental safety- remove clutter and hazards.

g. Use visual cues (eg signs and symbols) as reminders or to aid orientation.

h. Use routine practices when instructing/assisting the resident.

i. Record useful practices in care plan.j. Investigate the resident’s previous patterns and

incorporate into care plan (eg usual time of showering or preferred side of bed).

k. Ask family/relatives to visit at particular times of day to assist with management and care when able.

l. Consider the need for falls prevention equipment in keeping with local policies and in discussion and agreement with family and principal carer.

8. Continence:Do continence issues contribute to the resident’s falls risk?

a. If no toileting routine is in place, carry-out a continence assessment and/or review of continence chart.

b. Agree a toileting regime and use of continence products as appropriate.

c. Optimise environment safety - remove clutter and hazards, consider night lighting, monitor floors for wet areas - clean or report as soon as possible.

d. Ensure adequate hydration during the day, not excessive in late afternoon.

e. Provide with commode chair or urinal as appropriate.

Consider:f. If required, referral to district nurse or the

continence service.

4/7

Sample

11

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

9. Sensory impairment:Does the resident have poor vision? (Remember: following a stroke someone may have restricted vision on one side, some people with dementia experience visual problems?)

Does the resident have poor hearing?

a. If vision has not been tested in past 12 months, refer to optometrist.

b. Ensure room is free of clutter and obstacles.c. Ensure bedroom lighting is adequate, consider

need for night lights.d. Ensure glasses are in good condition, clean

(each morning), worn consistently (prompting, note in care plan), kept within reach when not worn, and appropriate (eg reading vs. distance)

e. If hearing has not been assessed in last 12 months, discuss options, including referral to audiologist with GP.

f. Ensure hearing aid is worn, clean and batteries are working.

g. Use common gestures/cues/instructions.h. Minimise excess noise.

10. Night patterns:*to be completed by night staff

Does the resident often get out of bed overnight?

If yes:

Is the resident able to get in and out of bed safely on their own?

a. Provide night lighting appropriate to vision.b. Optimise environmental safety – remove clutter

and hazards.c. Check bed height is suitable for the resident.d. Ensure spectacles and buzzer are within easy

reach.e. Discuss with family if nightwear is not

appropriate – consider especially slippers (should be good fit, with back and heel support) and length of nightgowns.

Consider:f. Treaded bed socks.g. Alert pad if resident is likely to fall while moving

around the room.h. Hi-low bed. Keep in a position to suit the

resident’s needs overnight.i. Provide with commode or urine bottle for night

toileting.j. If agitated at night: – Ensure calm environment and follow advice in the behavioural plan for settling the resident. – Observe every 15 to 30 minutes overnight. – Engage in regular activity during the day to aid sleep at night and/or reduce agitation during the day. k. Refer to GP for review of evening or night

medication.

5/7

Sample

12

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Risk factor (Tick if applicable, then link with recommended actions)

Recommended actions (Select appropriate interventions and record in care plan)

Date and sign

11. Feet and footwear:Does the resident have corns, ingrown toe nails, bunions, fungal infections, pain or loss of the sensation in their feet?

Does the resident wear ill-fitting shoes, high-heel shoes, or shoes without grip?

a. Refer to podiatrist (or GP if fungal infections). Start foot care regime.

b. Liaise with family to provide shoes with thin hard sole, enclosed heel, fastening mechanism.

c. Do not walk with socks only. If shoes are too tight or loose fitting, walk with bare feet.

d. Consider rubber tread socks if shoes are often removed.

12. New or respite resident:

Is the resident oriented to their new environment?

Does the resident have suitable clothing and footwear?

a. Orientation to facility/unit including their room, the bathroom, communal areas and outdoor areas.

b. Optimise environmental safety - remove clutter and hazards.

c. Inform and discuss with family/visitors as appropriate.

d. Refer to pre admission information to identify specific issues.

e. Liaise with family and principal carer to provide suitable clothing and footwear. Refer to information sent in from carer with regard to safety and falls risks.

Other:Are there other factors that you consider relevant in considering this resident’s falls risk, eg alcohol intake, pain, low mood/depression?

• Identify suitable action/s.

6/7

Sample

13

Tools for Managers – 2. Care homes multifactorial falls risk assessment and management tool (includes an osteoporosis risk screen)

Consider the relevance of the following risk factors:

Perceptual/Cognitive Physical Environment ActivitiesInsight/ judgementCognitive statusMemoryOrientationPsychiatric conditionAnxietyDepressionMotivationMedication effectsCommunicationNocturnal patterns

BalanceStrengthVisionHearingContinenceNutritional statusTime spent outsideMedical conditionMedication effectsSensationRange of movementFoot healthConstipation

FootwearAidsEquipmentClothingLightingFloor surfaceLocation of bedroomSeatingBedroom furnitureSignageContrasting colours

MobilityTransfersADLOpportunity for exercise High risk activityInactivityFitness

Action plan:

Risk factors identified Intervention strategies and referrals

Intervention listed in:

Care plan Hand over sheet

Date:

Signature and designation:

Review date:

Adapted from a tool developed by Westerlands Care Home, Stirling

Also known as Tool 5: Multifactorial falls risk assessment and management toolVersion no: 1 January 2015

Unique identification no: NR527d

7/7

Sample

14

Tools for Managers – 3. Care homes falls prevention monitoring form (walking aids/footwear/wheelchairs/commodes/chairs)

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1/2

Sample

15

Tools for Managers – 3. Care homes falls prevention monitoring form (walking aids/footwear/wheelchairs/commodes/chairs)

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2/2

Sample

16

Tools for Managers – 4. Care homes generic falls environmental risk assessment

Bathroom and shower rooms Area of consideration

Remedial action required to address significant finding

Yes No N/AAre floor coverings of bath/shower rooms a different colour from wall coverings?Are floor coverings provided with a non-slip surface?Are floor coverings free of defects?Is a system in place to ensure spillages are cleaned up without delay to prevent slippage risks?Are handrails positioned properly and securely next to toilet, shower and bath?Are raised toilet seats available which are well fitting and secure?Are non-slip mats used in bath/shower?Are receptacles for soap/shampoo easy to reach and do not require user to bend over?Do all shower chairs have adjustable legs, armrests and rubber stoppers on legs? Do commode chairs have wheels, castors, brakes that work smoothly and effectively?Do all shower chairs and commode chairs have seat belts or safety bars?Are areas immediately around bath and sink marked in contrasting colours?Is there room for a seat in/near shower?Are call buttons accessible from a sitting position in the shower?Is suitable transfer equipment (side loading trolley, hoist, etc) provided for users?Is bathroom/shower room free of stored materials that could present a tripping risk?Is bathroom/shower room door able to be opened/closed easily by user?Is bathroom/shower room free of a change in floor level?Is bathroom/shower room provided with adequate lighting?

Passageways Yes No N/AAre passageway floor coverings a different colour from wall coverings?Are floor coverings in passageways free of defects?

Generic Falls Environmental Risk Assessment1/4

Sample

17

Tools for Managers – 4. Care homes generic falls environmental risk assessment

Passageways Yes No N/AIs a system in place to ensure any spillages are cleaned up without delay?Are passageways provided with adequate lighting?Are passageways free of a change of floor level?Are adequate handrails provided along length of the passageway?Are passageways wide enough to allow people to pass each other?Are passageways maintained free of stored materials?Are doors across passageways maintained in the open position by hold open devices connected to the fire alarm?Are all cables positioned so that they do not present a tripping hazard to users?

Common dining areaAre floor coverings of dining area a different colour from wall coverings?Are floor coverings in dining area free of defects?Is a system in place to ensure any spillages are cleaned up without delay?Is the dining area provided with adequate lighting?Is floor covering in dining area free of change of floor level?Is dining area maintained free of stored materials?Are all cables positioned so that they do not present a tripping hazard to users?

Common loungesAre floor coverings of the lounges a different colour from wall coverings?Are floor coverings in lounges free of defects?Is a system in place to ensure any spillages are cleaned up without delay?Are the lounges provided with adequate lighting?Are floor coverings in lounges free of change of floor level?Is lounge area maintained free of stored materials?Is furniture in lounge area arranged so that tripping hazards are minimised?Are all cables positioned so that they do not present a tripping hazard to users?

2/4

Sample

18

Tools for Managers – 4. Care homes generic falls environmental risk assessment

Stairs and internal ramps Yes No N/AIs the height of the steps the same throughout the whole length of the stair or stairwell?Are the nosings (edge of step) square edged, highly visible and provided with a non-slip finish?Are steps of stairs free of defects and provided with a non-slip finish?Are suitable handrails provided on stairs?Are stairs provided with adequate lighting?If an internal ramp is provided has it been clearly identified?Is the floor covering on the ramp free of defects?Is the slope of the ramp suitable?Is ramp provided with adequate lighting?Is ramp provided with suitable handrails?

LiftsIs the lift floor covering a different colour from the wall coverings?Is floor covering in lift free of defects and provided with a non-slip finish?Are suitable handrails provided in lift?Are call buttons arranged so that they can be easily reached by users?Does the lift stop level with floor landing?Is the lift provided with adequate lighting?

ExternalAre external footpaths/areas used by residents (eg car park) even and free of defects?Is a system in place to ensure external routes are maintained free of slipping/tripping hazards eg falling leaves, moss, uneven paving, pot holesIs a winter maintenance procedure in place that monitors footpaths/roadways to ensure they remain free of contaminants eg ice?Are footpaths/roadways free of a change of level that present a tripping hazard?If a ramp is provided is the slope of the ramp suitable?If a ramp is provided is the surface free of defects?If a ramp is provided are suitable handrails provided?Are external footpaths, roadways and ramp provided with suitable lighting?Are door mats to remove possible contaminants from feet suitable?

3/4

Sample

19

Tools for Managers – 4. Care homes generic falls environmental risk assessment

References• Queensland Health general environmental checklist – www.health.qld.gov.au/fallsprevention/best_practice• All Wales Falls Framework - falls prevention document (draft)• Minimising the risk of falls & falls related injuries – Victoria Quality Council

Generic Environmental Checklist

The Generic Environmental Checklist pertains to the entire environment within the care home and its grounds where residents might spend some of their time.

Instructions for Use:• Overall responsibility to ensure the completion of the environmental checklist lies with the home

manager. This is necessary as remedial action may involve major and/or costly modifications to the area or changes in the operational activities within the area.

• The checklist should be carried out at least annually.

Tool developed by Carolyn Wilson, NHS TaysideAlso known as Tool 9: Generic Falls Environmental Risk Assessment

Version no: 1 January 2015Unique identification no: NR527f

4/4

Sample

20

Tools for Managers – 5. Care homes monthly falls overview form

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Sample

21

Tools for Managers – 6. Care homes post fall/incident report form

Resident’s name: Date of birth: Room number:

Date of fall/incident: Time of fall:

Fall location

Outdoors Bedroom En-suite Bathroom Corridor Sitting room Dining room Exact location

Surface type

Carpet Linoleum Other (specify)

Surface condition

Wet Damaged Slippery Other

Bed position

High Low Tilted N/A

Call bell in reach

Yes No N/A

Light

On Off N/A

Mobility

Ambulant Non-ambulant Independent Assistance of 1

Assistance of 2

Aids

None Stick Walking Frame Crutches Wheelchair

Post fall/incident report form1/4

Sample

22

Tools for Managers – 6. Care homes post fall/incident report form

Was aid used at the time of fall?

Used correctly Used incorrectly Not used

Unknown Condition of aid

Type of fall

Slip Trip Collapse Legs gave way Loss of balance Unknown

Falls direction

Drop Forwards Backwards Sideways Unknown

Any warning prior to fall

Dizziness Faintness Confusion Fit

Loss of consciousness Palpitations Aggression Breathlessness Altered mental state None of above/other (specify)

Toileting

Resident attempting to go to toilet Incontinence Frequency Urgency

Footwear

Shoes Slippers Socks Bare feet Condition

Glasses

None Reading Distance Bi-focals Vari-focals

Type worn at the time of fall

None Reading Distance Bi-focals Vari-focals

Condition of glasses

History of falls

No Yes Number of falls in past 12 months

Medication/substance use - potentially a contributory factor?

Yes No N/A Unknown

Time taken

Medication/substance identified

2/4

Sample

23

Tools for Managers – 6. Care homes post fall/incident report form

Description of event

Was the resident aware the fall was going to happen? Yes No Unknown

Residents description of fall including activity immediately prior to falls

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Brief description of fall. What was seen or heard. Witnesses description (note any incontinence or abnormal movements).

______________________________________________________________________________________

______________________________________________________________________________________

______________________________________________________________________________________

Witness name/status: __________________________________________________________________

Clinical observation/vital signs following fall

Vital signs checked following fall Yes No N/A(BP, pulse, respiration)

Any noticeable changes in residents health Yes ______________________ No(note any pallor or cyanosis)

AMT required Yes No N/A AMT Score: _________________

First aid administered Yes No N/A

Hospital attendance required Yes No N/A

Injuries sustained: Fracture: Yes No Head injury Yes No

Laceration/bruising Yes No

Other (specify): ______________________________________________________

Immediate action taken _________________________________________________________________

______________________________________________________________________________________

Doctor notified Yes No Time notified: _______________________________

Seen by doctor Yes No Time seen: ________ Doctors name: _____________

3/4

Sample

24

Tools for Managers – 6. Care homes post fall/incident report form

Outcome (note if RIDDOR reportable)

Action taken to prevent re-occurence (please specify)

Falls risk assessment/care plan updated? Yes No N/A

Environmental risk updated? Yes No N/A

Assessed by

Date

Tool developed by Carolyn Wilson, NHS Tayside and Jerry Forteath, Angus Council Social Work and Health

Also known as Tool 10b: Post fall/incident report formVersion no: 1 January 2015

Unique identification no: NR527h

4/4

Sample

25

Annex A – Care homes post fall pathway

A resident has fallen or has been found on the floor

Assess resident’s responsiveness and for any injury (including cuts, bruising, deformities or pain)

No obvious injury sustained Obvious injury sustained

• Check for any pain, swelling or abnormality.• Check understanding and comprehension.• If in any doubt follow procedure for obvious

injury.

Once established as far as reasonably practicablethat there has been no obvious injury sustained, correct moving and handling practice should be followed to assist the resident from the floor.

Independent person:Verbally talk throughrising from the floor.

Dependent person:Appropriate hoist/floor lifting cushion must be used to lift from floor

Safe to move person

Not safe to move person

Call ambulance/GP/NHS 24

• Do not move the person (unless in immediate danger of further injury).• Call for assistance/alert senior staff.• Keep person warm and note any changes.• Assess level of injury, provide reassurance and take

appropriate action (eg call ambulance/GP/NHS 24).• If competent take vital signs eg BP.• Attend to superficial wounds.• Injury to head suspected – ongoing observation for

neurological changes.

Notify next of kin as agreedCommence falls investigation

Complete accident/post falls report form to determine causes/circumstances of fall

Compile an action plan from the above finding to reduce the risk of a similar fall occuring again

Refer on to appropriate services if required

Review falls risk assessment/care plan and update as required

Complete individual falls record and/or care home falls record

Complete incident reports as required by organisation

Communicate to all relevant staff that individual has fallen and has an increased chance of falling again

Discuss with individual and their family the circumstances of falls, the consequences and action plan to reduce further risk, including any referral on for further assessment/intervention

STAGE 2

STAGE 1

For Stage 1see sectionA6 for moredetail

Adapted from tool developed by Carolyn Wilson, NHS Tayside

Ensure ongoing monitoring of individual as some injuries may not be apparent at the time of fall. Observe individuals who are taking anticoagulants or antiplatelets carefully because they have an increased risk of bleeding and intracranial haemorrhage.

Pathway for managing a resident who has fallen or who has been foundon the floor

Also known as Tool 8: Pathway for managing a resident who has fallen or who has been found on the floor

26

Annex B – Care homes had a fall poster

With acknowledgement to Berkshire Health Promotion

27

Annex C – Medicines associated with falls

Taking certain medicines can make you more likely to fall. However, while they may contribute to falls in some people, they don’t cause falls in everyone. Medicines act in different ways, e.g. Medicines acting on the brain can cause drowsiness, loss of balance and slow reaction times Medicines that lower blood pressure or slow the heart can cause faintness, dizzy spells or ‘legs

to give way’ e.g. blood pressure may suddenly fall when standing up or stretching.

People on FOUR or more medicines (polypharmacy) are at greater risk of falling. Regular medication reviews play an important part in preventing medicines-related falls.

.

Refer to British National Formulary (BNF) latest edition for further examples of medicines listed above

Common examples of medicines acting on the brain:

Sleeping tablets and anxiety treatments e.g. temazepam, diazepam, zolpidem, zopiclone, Some antidepressants may cause drowsiness* e.g. amitriptyline, mirtazapine, citalopram,

fluoxetine Some antidepressants may cause dizziness e.g. venlafaxine, duloxetine Strong painkillers e.g. codeine, tramadol, fentanyl Antipsychotics* (medicines for mental health problems and agitation) e.g. olanzapine,

quetiapine, risperidone, haloperidol Medicines for Parkinson’s disease* e.g. co-beneldopa and co-careldopa Some antihistamines e.g. chlorphenamine and cinnarizine Medicines for epilepsy e.g. phenytoin and carbamazepine Medicines for nausea, vomiting, travel sickness e.g. cyclizine

*these medicines can also lower blood pressure

Common examples of medicines that lower blood pressure or slow the heart: Medicines to treat high blood pressure and heart disease e.g. digoxin, doxazosin, lisinopril,

losartan, amlodipine, diltiazem, atenolol, glyceryl trinitrate, fluid tablets (examples below)

MMMeeedddiiiccciiinnneeesss aaassssssoooccciiiaaattteeeddd wwwiiittthhh fffaaallllllsss

Other commonly-used medicines known to increase the risk of falls: Medicines for dementia may cause fainting or dizziness e.g. donepezil, galantamine,

rivastigmine and memantine Medicines for diabetes may cause dizziness e.g. insulin, pioglitazone, gliclazide Medicines for bladder overactivity may cause blurred vision e.g. oxybutynin, tolterodine Some eye drops or eye ointments may cause blurred vision e.g. latanoprost, pilocarpine Fluid tablets may cause rushing to the toilet e.g. bendroflumethiazide, indapamide, furosemide Laxatives may cause rushing to the toilet e.g. senna, macrogols

IIIfff aaa rrreeesssiiidddeeennnttt ssseeeeeemmmsss tttooo bbbeee aaattt aaannn iiinnncccrrreeeaaassseeeddd rrriiissskkk ooofff fffaaalllllliiinnnggg ddduuueee tttooo ttthhheeeiiirrr mmmeeedddiiiccciiinnneeesss,,, ttthhheee cccaaarrreee---hhhooommmeee nnnuuurrrssseee ooorrr mmmaaannnaaagggeeerrr ssshhhooouuulllddd

dddiiissscccuuussssss ttthhhiiisss wwwiiittthhh ttthhheee rrreeesssiiidddeeennnttt’’’sss ppphhhaaarrrmmmaaaccciiisssttt ooorrr GGGPPP...

March 2013

28

Copyright © 2015 Care Inspectorate

All rights reserved

Printed January 2015Planned review January 2016

Sutton and Merton Community Services120 The BroadwayLondon, SW19 1RH

www.smcs.nhs.uk

The Care Inspectorate and NHS allow all or part of the text of this document to be reproduced, free of charge, in any format or medium provided it is not for commercial gain. The text may not be changed and must be acknowledged as Care Inspectorate and NHS copyright with the document’s date and title specificed.

This booklet is evidence based wherever the appropriate evidence is available, and represents an accumulation of expert opinion and professional interpretation.

This resource pack has been adapted from the ‘Managing falls and fractures’ Resource Pack as developed by, and with kind permission of, the Care Inspectorate. The full resource can be downloaded at: www.careinspectorate.com

Details of the references used in writing this booklet are available on request from: The Royal Marsden Help CentreFreephone: 0800 783 7176Email: [email protected]

No conflicts of interest were declared in the production of this booklet. The information in this booklet is correct at the time of going to print.

NR527 Version 1, January 2015