Falls Awareness and Assessment in Care Homes.

© Staffordshire County Council 2015

Contents Page Section 1 - Overview – aims, objectives, background………………………………….. 3 Section 2 - Falls in Care Homes………………………………………………………………4 Section 3 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9 3.91 3.92 3.93

6 Falls Risks……………………………………………………………………….. Environmental Hazards…………………………………………………………6 7 Medication………………………………………………………………………… 9 Physical Activity, Falls & Function………………………………………………. 11 Vision………………………………………………………………………………. 12 Neurological Impairment……………………………………………………………. 12 Urinary Incontinence & UTI’s…………………………………………………….. 13 Osteoporosis & Nutritional Status………………………………………………… 14 Fear of Falling……………………………………………………………………… 16 Foot care & Footwear………………………………………………………………. 17 Alcohol & Substance Misuse…………………………………………………….. Hip Protectors…………………………………………………………………….18 18 Staff Training………………………………………………………………………

Section 4 - Assessment of Falls in Care Homes………………………………………………. 19 Section 5 – Introducing a Falls Prevention Policy…………………………………………… 41 Appendices – Example Forms………………………………………………………………..42 47 Bibliography……………………………………………………………………………………….

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Section 1 – Aims, Objectives & Background Aims •

To reduce the frequency of falls in care homes

•

To reduce the seriousness of falls that do occur

Objectives •

To give an understanding of the risk factors of a fall

•

To facilitate the implementation of a comprehensive, person centred multi-factorial falls risk assessment in the care home

•

To suggest practical interventions that may reduce these risks

Background to Falls Falls are a major cause of injury, disability and mortality to the over 75’s in the UK and 14’000 people a year die after suffering an osteoporotic hip fracture1. Just under 9,300 people aged over 65 (equivalent to roughly 1% of Staffordshire’s total population) are predicted to attend hospital A&E departments in 2010 having experienced a fall2. In care homes older people are three times more likely to fall than their peers living in the community3. As well as the cost of treating falls financially and in NHS bed days, the experience of a fall can have severe human consequences affecting the quality of life of the faller. Human consequences of a fall include:-

•

A decline in physical function and decreased mobility

•

Loss of independence

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Loss of confidence, increased anxiety in every day tasks

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Social isolation

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Fractures to wrist, hip and back

__________________ 1. National Strategic Framework Older People :Standard 6. 2001 2. Staffordshire Joint Commissioning Unit 2008 3. Preventing Falls. Managing the risk and effect of falls among older people in Care Homes. Help the Aged. 2004

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Section 2 - Falls in Care Homes Help the Aged3 suggest that an older person in a care home is three times more likely to fall than a person living in the community. This may occur for several reasons:

•

40% of residents are in the home due to a previous fall, which in itself is risk factor of another fall4.

•

Half of older residents fall in a 12 month period and 40% fall more than once a year4.

•

Residents are more likely to be frail with medical conditions and taking several medications.

•

Limited activity reduces functional strength.

•

Where independence is encouraged residents risk can be increased.

•

A new environment can reduce self confidence.

However it is important to note that falls are not an inevitable consequence of getting older and are often caused by a variety of factors and by implementing a person centred, multi-factorial approach to falls prevention the risk to residents can be decreased. For this reason it is recommended that this document initially be used to take a whole systems approach to falls and not just pick out 1 or 2 interventions What is a Fall? A fall is defined as “a sudden, unintentional change in position causing an individual to land at a lower level, on an object, the floor, or the ground other than as a consequence of paralysis, epileptic seizure or other overwhelming force”5 Contributing risk factors to a fall The contributing factors to falls are split into two main categories intrinsic (individual factors e.g. a persons balance) and extrinsic (environmental factors e.g. trip hazards). These factors can either be modifiable (factors we can influence) or non modifiable (factors we can’t influence). _________________ 4. Todd C, Skelton D (2004). What are the main risk factors for falls amongst older people and what are the most effective interventions to prevent these falls? Copenhagen WHO Regional Office for Europe (Health Evidence Network report. 5.Gibson et al. The prevention of falls in later life. A report of the Kellog International Working Group on the prevention of falls by the elderly. Danish medical bulletin.1987;34(supp 4):pp1-24.

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Reducing the risk of falls is achieved by altering the modifiable factors to reduce the risk. This document details the most common modifiable risk factors and suggests ways that these factors can be altered to reduce the risk of a fall occurring. It is important to note that following the recommendations will not stop falls happening, however the information is based on current known best practice and recommendations for lowering the potential of a fall occurring. Recording Falls When a fall or a near miss occurs at a care home it is very important to record as much detail as possible about the nature of the incident. Recording the detail of the incident has two main benefits. 1) Identifies any interventions that could be put in place to reduce the risk to the individual. 2) Identifies any patterns that are occurring within the home that may need to be addressed. For instance, if the majority of falls occur at certain times can staff shifts be changed to ensure maximum staffing at that particular time, or is a feature of the home e.g. flooring, causing falls and needs to be changed. The type of information that should be recorded is. Who fell? Where they fell? What time did they fall? Cause of the fall (if known)? Injuries suffered? Immediate intervention put in place to reduce risk of similar fall? Long term action to reduce risks (if applicable)? See appendix 3 for example form. NB – This information is extra to and does not replace any official or legally required documentation or reporting procedure.

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Section 3 – Falls Risks

3.1 Environmental Hazards Environmental hazards are factors around the home that may cause a person to trip or fall. They should be covered in your homes general risk assessment under the Health & Safety at Work Act 1974 as many of the risks are a risk to all not just residents. The Health & Safety Executive publishes the document Health & Safety for Care Homes, which details relevant legal, managerial and technical matters in regards to Care homes. This can be downloaded for free of charge at http://books.hse.gov.uk by using the search phrase “Care Homes” in the search facility of the website. The following is a brief overview of risk assessment however it is strongly recommended that the HSE document is read and followed. Most environmental risks can be grouped into one of three areas. a) Physical Environment b) Housekeeping c) Equipment Each of these areas needs to be taken into consideration when carrying out your risk assessment. Below are suggestions of factors that might contribute to a slip, trip or fall. Environmental Risk Assessments carried out should be specific and relevant to your particular premises. This list is by no means comprehensive and is for guidance only. a) Physical Environment Flooring – is it non slip, how does it wear e.g. loose carpets, how is it cleaned? Design – do the premises meet the needs they are serving e.g. sufficient electrical sockets to reduce trailing wires, are aids and adaption’s in the right place? Furniture – is it suitable for residents, are chairs and beds the correct height for safe transfers? Fire – are fire procedures in place and does the building allow for safe evacuation of staff and residents?

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Lighting – is the home well lit, are sudden changes in light intensity avoided and is glare kept to a minimum? Colour – are colours used to distinguish changes in surfaces, edges etc? Patterned floors and carpets should be avoided as they can cause confusion and disorientation. b) Housekeeping General tidiness – are all rooms kept free of clutter and potential trip hazards? Fixtures & fittings – are the premises well maintained, rails and handles checked and secured. Are there reporting and action procedures in place for faults? Residents rooms – are these checked regularly for clutter and hazards? Staff & residents – is everyone proactive in helping maintain a safe environment for all? c) Equipment Maintenance – is there a schedule in place to test, maintain and replace equipment where necessary? Operation – is equipment only operated by those trained to do so? Aids and Adaption’s – are the aids and adaption’s appropriate and fit for purpose? An example Environment Risk Assessment Form is included in Appendix 1 Occupational Therapy Risk Assessments Some OT services will also be able to offer advice and assessments from their professional point of view and it may be worth asking if one can be done on your premises. 3.2 Medication a) Poly-pharmacy The major falls risk from medication is poly-pharmacy. Patients on 4 or more medicines are at a greater risk of falling and therefore a 6 monthly medication review is advisable for residents on more than 4 prescribed medications. b) Psychotropic drugs Tranquilizers, mood enhancers and other drugs used to treat mental health issues have in some studies been shown to increase falls risk and they should only be used where

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absolutely necessary and for the minimum time possible. Drugs of this type include, antipsychotics, benzodiazepines and hypnotics. For residents taking these types of medications a 6 monthly review should be undertaken to ensure medication is only used as and when needed. This review should also take place whenever there is a change in the residents condition. c) Anti-hypertensive’s Drugs used to lower blood pressure, if not monitored, may lead to orthostatic hypotension and leave a resident susceptible to falls. Beta Blockers are the main group of drugs associated with falls, however, any group that lowers blood pressure where used in conjunction with each other may lead to hypotension and increase the risk of a fall e.g. ACE inhibitors, Diuretics. d) Diuretics / Laxatives Dehydration can also be a contributing factor to a fall and this can be caused if a patient in taking laxatives or diuretics. e) Diabetes Control Poor diabetes control impacts on the risk of falling in several ways. Peripheral neuropathy (loss of feeling in extremities e.g. fingers / toes) occurs over time and this can effect a persons balance as they have less feeling in the feet. Ensure that suitable foot wear is worn with soles that are not too thick so the person can feel the surface they are walking on. Diabetics should have a regular foot check up from a chiropodist or podiatrist to check for other foot care issues. Another risk for diabetics is the risk of fall during a hypoglycaemia or hyperglycaemia episode and to reduce this risk staff should work with the resident on a regular basis to ensure that blood sugars are controlled. If a person with diabetes is starting to exercise or significantly increase the amount of general activity they take part in it is important to take advice from a suitably qualified Health / Exercise Professional to monitor the persons blood sugars. An increase in energy demand will alter the amount of sugars used for energy and therefore the diet or drug regime may need to adapted to ensure blood sugars are kept stable. A sensible option when a session is taking place with known diabetics is to make

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sure a sugary drink, gel or food is available that is easily administrable in the event of a hypoglycaemic episode. Each resident should be offered a medication review at 6 monthly periods from a GP or Pharmacist. With all medication it is essential that the person is compliant with their prescription and takes the correct medication at the correct time. This section is not exhaustive and if unsure about medication a suitably qualified person should check the British National Formulary (BNF) manual. This will also detail any combinations of drugs that may cause contra-indications.

3.3 Physical Activity Falls & Function For more detailed information on general physical activity see the Caring for Health Physical Activity guidance document.

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Insufficient activity (including activities involving strength, balance and coordination) can lead to the following, all of which can be linked to an increase risk and severity of falls. o Reduced muscle mass and loss of strength o Reduced reaction times o Changes in the way people walk (gait) o Loss of bone density and potentially osteoporosis o Poor balance proprioception

•

Incorrect size, type and usage of assistive mobility devices (such as crutches, walkers etc) is also a risk factor.

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Physical Activity and Falls The following recommendations are the latest guidance from the Department of Health5 The majority of people who fall tend to display weaker lower body muscle groups (quadriceps, hip and ankle) than peers who have not fallen and this is compounded by decreasing sensory perception which exacerbates the inefficiency of the musco-skeletal system. The latest guidance on physical activity and falls is;
Although any increase in physical activity will benefit the individual not all activity may reduce the risk of falling.
Exercise prescription will differ depending on the individual
Exercise to prevent first falls could involve Tai Chi and other balance and strength training activities.
Exercise to manage falls should include dynamic balance, strength and functional floor activities. It should aim to include bone loading, power, flexibility, postural, and gait training, supported endurance work, and tasks to improve visual and sensory input.
Exercise to manage falls can be home or group based and should be delivered by specialist trained professionals.
If the person has a history of falls, exercise should be used to retrain or maintain the ability to get up of the floor to avoid a long lie. Poor Functional Ability / Poor Gait / Poor Balance Individuals with poor general functional ability should be encouraged to be active through formal and if possible individually prescribed exercise as well as specific activities that may improve their functional ability. If an individuals gait is affected it is recommended to seek the professional input of a Physiotherapist on exercises that would improve this. ___________________

5. Falls & Fractures – Exercise Training to Prevent Falls – DoH 2009

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Poor gait can be generally by recognised by;
Slowness in walking
Decreased stride length
Forward leaning at head and torso
Increased lateral sway
Increased flexion at knees and shoulders There are many factors that can affect gait and some of these are covered elsewhere in the falls assessment including foot care and foot wear, poor functional ability, fear and vision. Others to be aware of include, inner ear problems, degenerative diseases and the central nervous system. To summarise all general physical activity is good and MSE and Tai Chi may reduce the risk of falls in people who have not yet fallen. However in people who have fallen and those with poor functional ability and gait, it is recommended that they receive a specific individual exercise prescription from a suitably qualified professional. It is also advised to do an individual Risk Assessment for activities that residents take part in (for example see Appendix 2) and this should be done positively to inform what the resident can do. 3.4 Impaired vision There are many conditions that can affect eyesight as we age and increase the risk of falling, for example, cataracts, glaucoma and macular degeneration. It is recommended that residents have eye tests at regular intervals, aged under 70 bi-annually and aged over 70 annually. There are simple ways to reduce the impact of vision on falls;
Resident should wear glasses where prescribed
Glasses should be of appropriate prescription
Glasses should be clean and in good order
There may be a risk if the resident wears bi focal lenses whilst moving around
Make sure resident is wearing correct glasses for the activity they are doing

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Make sure all rooms are well lit
De-clutter rooms to avoid trips. 3.5 Neurological impairment This covers wide array of issues such as Dementia, Parkinson’s Disease and Stroke and the resulting symptoms will manifest in different ways in individuals. Common symptoms could be confusion, feeling lost, loss of memory and wandering. There is no one solution to this issue. You will need to work closely with the resident and their family, looking at routines, medication, assistive devices to ensure that the symptoms are risk assessed and managed as practically as possible. Specific condition risks include (but are not limited to) Cognitive Impairment – difficulty judging distances, failure to notice and understand hazards, may not remember warnings and tricks of the mind. Dementia - forgetting hazards and warnings, confusion, poor motor control, anxiety, drugs used to treat can cause low blood pressure. Parkinsons Disease – slow reflexes, freezing of limbs, unsteady on feet, poor balance and coordination. 3.6 Urinary incontinence (UI) and Urinary Tract Infections (UTI) UI Residents suffering urge urinary incontinence may have an increased risk of falling due to the increased sense of urgency to use the bathroom. If you have a resident who is suffering from urinary incontinence then a referral to a GP to help control the condition is appropriate. On a day to day basis a risk assessment should be done for activities that the resident takes part in, in relation to the condition. Residents who also have to urinate during the night on a regular basis are also at an increased risk of falling. A risk assessment should also be done to manage the risk e.g. assistive devices, commodes and adequate lighting are options that may be explored.

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UTI As well as increased frequency of urge, if a UTI is left untreated it may result in confusion which in turn increase the risk of the resident falling. If a UTI is suspected or diagnosed the appropriate treatment should undertaken through the residents GP or appropriate health professional. 3.7 Osteoporosis Regardless of what procedures are in place people will still fall and therefore risk injuring themselves. The severity of injury will depend not only on the nature of the fall but also the physical condition of the resident. Osteoporosis is basically a condition where the bones of the body are less dense and therefore not as strong as they should be. The condition can affect men and women but is more common in women and frail older adults. There are many risk factors associated with the development of osteoporosis including smoking, early menopause and a sedentary lifestyle. In order to diagnose the condition a person would have to undergo a bone scan after referral from an appropriate medical professional normally a GP. Osteoporosis is not a reversible condition and in people who have the disease treatment is therefore based on retaining bone density. In a care setting it is essential that the home takes steps to make sure that all residents have access to the correct medication (where applicable), nutrition and physical activity to retain bone density. It is also important that residents are able to access sunlight as this helps with the creation of Vitamin D. See the Going Outside section of the Physical Activity Guidelines for more information. From a nutritional view the risk of osteoporosis increases with:
Vitamin D deficiency, linked mainly to inadequate exposure to sunshine, and / or
Reduced calcium stores, caused by age-related changes to the amount absorbed by the gut and hormonal changes (reduced oestrogen levels in women associated with the menopause), leading to increased calcium loss.

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Inadequate amounts of either or both of these nutrients can predispose people to, or actually hasten the onset of osteoporosis (brittle bone disease), especially in individuals at increased risk of the condition (e.g. those with a family history of the condition, older post-menopausal women or women who have had an early menopause or hysterectomy etc.). Osteoporosis in its own right is an independent risk factor for falls.
Malnutrition and an associated decrease in muscle mass and strength also increase the risk of falls occurring in an individual.
Even a modest degree of dehydration can lead to deterioration in mental state, causing confusion, dizziness and an increased risk of fainting and falls. For more information on nutrition see the Dietary Supplementation section of the Nutrition section of the Caring for Health award. There are a variety of medications that can be prescribed to treat osteoporosis and staff should ensure that residents are compliant with the prescription to ensure the treatment is effective. Tese topics are covered in more detail in the relevant Caring for Health manuals that can be accessed by taking part in the Caring for Health Award.

3.8 Fear of Falling and Encouraging Activity

The fear of falls not only effects those at risk, in today’s litigious society some care providers may steer away from encouraging physical and social activities and encouraging an ethos of independence due to the risk of a fall and the resulting legal action that may follow. However the benefits of encouraging people to be social and active, both physically and mentally far outweigh the risks associated with activity. Falls will always happen no matter how much risk is reduced, but as long as appropriate risk assessments are in place and appropriate guidance followed to minimize the risks then the likelihood of any legal comeback is minimised.

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Recent Department of Health Guidelines on Falls & Fractures5 suggests the following ways to promote activity:
Focusing on promoting activities that improve strength and balance is more successful in maximising participation than in promoting activities that focus on falls prevention.
People should have a choice of suitable activities available to them.
Activities should not be avoided because they are hazardous.
Physical restriction such as wearing hip protectors should not be focused on as it is overbearing. The main messages to be promoted are; falls are a risk but are not inevitable, staying active and dealing proactively with conditions will reduce frailty and preserve independence and encourage people to seek a falls assessment if they feel that they have a condition that is worsening. There will always be individuals who are reluctant to get involved due to the fear of falling. In these cases it is up to home staff to work with resident to build their confidence to take part in appropriate activities. One way of doing this could be to work with health and exercise professionals to adapt activities to help the resident take “small steps” towards full participation in the activity where possible. On the other hand an over confident resident is at risk of falling due to not realising or wanting to admit the limitations of their motor abilities. Again staff should work with the resident closely and see activities can be adapted to allow them to participate safely. In Don’t Mention the F word Age Concern6 suggest the way in which advice is given can effect as to whether or not the advice is acted upon. To summarize the findings, residents responded better to suggestions that they should be more active when there was less focus on falls and more on the other benefits of being active e.g. walk further, stand longer and more social interaction. In the forward of the second edition of Age Concerns, The Successful Activity7 a couple of scenarios are described. __________________ 6. Don’t Mention the F word. Age Concern 2005 7.The Successful Activity Coordinator. Age Concern. 2005

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In the first it is the improvement in the quality of life of a disengaged resident with dementia who is moved into a specialist home who due to the specialist care and activities provided re-engages and takes a more active role in the day to day activities at the residence – the authors overarching comment, “smiles don’t lie” sums up the improved motivation and quality of life of the resident. The second example involved balancing risk with quality of life, a previously active 90 year old nurse crippled with arthritis and heart failure asked to go horse riding. This was duly arranged through a disabled riding centre and even though the activity caused the lady chest pain – “the smile of satisfaction outweighed the risk taken”.

3.9 Foot care and Footwear There are two aspects of foot care that can contribute towards reducing the risk of falls that are very closely linked. Firstly it is important that feet are well cared for in order to prevent and treat issues such as in-growing toe nails and bunions etc that cause pain when walking. Painful walking can cause people to become less active in general and therefore at greater risk of falling. Secondly, the pain could also mean individuals become more tentative when walking which again will increase the risk of a fall. To reduce the risk of falls due to these problems care homes should ensure that each resident has access to community or private chiropody services. Podiatry services will look at the bigger picture of foot care. A podiatrist will be able to advise residents on the following types of information; chronic medical conditions that affect feet such as diabetes and rheumatoid arthritis, minor surgery such as surgical removal of corns or toenails under local anaesthetic, mechanical problems that can be helped by special insoles and exercise regimes, and advise on correct footwear to reduce the risk of slips and trips. Footwear Wearing suitable footwear in good condition has been recognised as a way of reducing the risk of falling, some of the essential points to look out for in good footwear are;

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Heel height: flat shoes or shoes with built in heel
Soles, non slip is important, avoid smooth, leather soles
Flexible, and not too thick, as this affects balance
Snug fit with room to move toes and deep enough to accommodate foot
Lightweight and supportive
Securely fasten with Velcro, laces or buckles to provide secure hold
Keep shoes, particularly the soles, clean of any greasy, slippery deposits.
Soft, flexible uppers for comfort
Smooth and seam free inners with no rough edges

Slippers Safe slippers are as important as safe shoes and should be replaced when they become worn. Residents should be dissuaded where possible from wearing flip flop, backless and worn out slippers and be encouraged to wear shoes or sturdy house shoes as often as possible. Where slippers are worn they should be in good order, be sturdy, have fasteners, preferable Velcro type and have sturdy but not thick soles.

3.91 Alcohol and Substance misuse As with any individual a high alcohol intake increases the risk of falling. In older people this risk is increased as;
A lower body mass may reduce tolerance to alcohol
Alcohol also acts as a diuretic increasing the risk of dehydration and falling
Prescribed and non prescribed medication may interact with alcohol
Taking any mind altering substance increases the risk of falling The current recommended advice for alcohol for adults is;
Men should drink no more than 21 units of alcohol per week (and no more than four units in any one day)

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Women should drink no more than 14 units of alcohol per week (and no more than three units in any one day). However, as mentioned, in reality these amounts may be lower for older adults to drink safely. Residents should be advised on the drinking limits and made aware of the issues of alcohol but in a way that respects dignity. Residents should also be warned about the dangers of taking non prescription medication and substances.

3.92 Hip Protectors Hip protectors are a contentious issue in falls especially around adherence to the wearing of them. In order for a hip protector to be effective it needs to be worn 24 hours a day and some cases of issues of compliance with wearing them have been reported. If it is felt that a hip protector is needed the advice of a medical / health professional should be sought. A hip protector should also only be used as part of the wider multi-factorial assessment and should not be used in isolation. 3.93 Staff Training Staff training and education on falls awareness has been shown to be effective in helping reduce the incidence of falls in care homes. This training should include all staff and be carried out on a regular basis as refresher training for existing staff and initial training for new staff. Any training should be documented as part of your homes risk assessments and for staff development purposes.

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Section 4 - Assessment of Falls There are many tools that have been used to identify the level of risk a patient is at in relation to falling. Most of the tools work on a scoring basis and group people as low, medium and high risk. However 40% of residents are admitted to a residential home after a fall, 50% of residents will fall in a 12 month period and 40% will fall twice in 12 months. Due to these figures this award assumes that all residents are at a degree of risk and therefore a regular multi-factorial falls assessment should be carried out on all residents and the appropriate interventions put in place through their care plan. Therefore this section of the document is derived from NICE Guidance and its recommendations for a Multi Factorial Falls Assessment and appropriate interventions. When a risk has been identified the appropriate intervention should be put in place and these interventions should be built into the individuals care plan. Every resident should have a Falls Assessment review on a regular basis (up to 6 months), after a fall or a near miss and if a condition associated with falls risk changes. It is important to note that the interventions are approached in a multi-factorial way looking at the whole individual rather then just individual risk factors.

NB – This assessment is not intended to replace a Falls Assessment carried out by Medical and Health Professionals.

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Care Home Falls Risk Assessment

Resident name: Date Assessment Completed: Assessment Completed by: Latest Reassessment Date: (within 6 months of this assessment add to care plan)

Major Risks Identified (e.g. previous falls details)

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Completing the Falls Risk Assessment This Falls Risk Assessment process will not score a resident as being at low, medium or high risk of falling, it simply helps to identify risks that can then be modified to reduce the overall risk of falling. It is aimed at providing a system that goes through a simple step by step process identifying the risks and suggesting ways of modifying these factors. The document is simple to complete and should be used as part of a residents care plan. Some of the information can be transferred from the care plan e.g. medication information, as long as it is up to date. The assessment can be completed by care workers however input will be required by a medical / health professional on certain areas. This assessment should be completed for each resident 1) On arrival into the home (within 48 hours) 2) After a fall, or near miss 3) At least 1 on a 6 monthly basis 4) If a condition changes To use the document simply answer the question and follow the appropriate pathway. Follow the advice given in the appropriate pathway, refer to the Falls Guidance Manual for further information, sign and date when the intervention has been identified and then when implemented. If there is no action to be taken then initial & date the no action box. There is also room for notes to be made on the page for more detail of interventions implemented.

NB – The assessment should be done with the resident where possible and take into account their dignity and wishes. 21

Risk – Previous Fall Has the resident had a fall in the last 12 months? Action identified Date & Initial

Yes 1. Contact local falls service for referral (if resident not referred) 2. Can the resident be given a Falls Prevention Exercise programme 3. Carry out individual Risk Assessment for activities around the home 4. Carry out remainder of assessment

Action Completed Date & Initial

1.

1.

2.

2.

3.

3.

4.

4.

No Carry out remainder of assessment

Details of Previous Falls etc.

Notes

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Risk – Medication (Reference section 3.2) Is the resident taking more than 4 prescribed medications? Action identified Date & Initial

Yes

Order GP / Pharmacist personal medication review if one hasn’t been done for the resident in the last 6 months

1.

Action completed Date & Initial

1..

No No action

Notes Name & Position of Prescription Reviewer Practice Reviewer recommendations:

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Risk – Medication (Reference section 3.2) Is the resident taking a psychotropic or hypertensive medication and are they compliant with prescription? Action identified Date & Initial

Yes 1) Order GP / Pharmacist personal medication review if one hasn’t been done for the resident in the last 6 months or if there is a change in the residents condition. 2) Advise resident on compliancy issues where appropriate.

Action completed Date & Initial

1.

1.

2.

2.

No No action

Name & Position of Prescription Reviewer

Notes

Practice Reviewer recommendations:

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Risk – Functional ability (Reference section 3.3) Is the resident unsteady on their feet and / or finds it difficult to balance? Action identified Date & Initial

Yes 1. Can the resident be referred to Falls Service / Physio / OT for assessment and intervention? 2. Can a personal exercise prescription off a suitable professional be arranged. 3. Ensure the resident has access to the appropriate aids & adaption’s.

Notes

1.

Action completed Date & Initial

No

1.

2.

2.

3.

3.

1. Use Care Plan to help the resident stay as physically and socially active as possible to help retain function.

Resident referred to. Type of aids & adaption’s ordered 25

Risk – Functional ability 2 (Reference section 3.3) Does the resident struggle with activities of daily living? Yes 1. Encourage resident to be more active through activities of daily living and increased physical activity (see award PA guidelines) 2. Ensure the resident has access to the appropriate aids & adaption’s. 3. Referral to OT / Physio to improve function. 4. Arrange for a personal exercise prescription off a suitable professional if available.

Notes

Action identified Date & Initial

1.

Action completed Date & Initial

No

1. To maintain function follow YES pathway

2.

2.

3.

3.

4.

4.

Mobility issues.

Referrals made.

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Risk – Sedentary Lifestyle (Reference section 3.3) Is the resident physically active? (see Physical Activity guidelines of award)

Yes 1. Encourage resident to carry on being active and taking part in activities of daily living. 2. Give advice on MSE exercises (see PA guidelines) 3. Can an individual exercise programme be developed for the resident by an appropriate professional?

Action identified Date & Initial

1.

Action completed Date & Initial

1.

2.

2.

3.

3.

No 1. Work with resident to see what would encourage them to be more active. 2. Can an individual exercise programme be developed for the resident by an appropriate professional? 3. Encourage residents to be as active as possible through activities of daily living and occupation

Action completed Date & Initial

Action completed Date & Initial

1.

1.

2.

2.

3.

3.

Notes

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Risk – Vision 1 (Reference section 3.4) Has the resident complained of deteriorating vision?

Yes

1. Is the resident wearing the correct glasses 2. Are glasses in good order and cleaned regularly 3. Arrange eye test as per homes policies and procedures

Action identified Date & Initial

Action completed Date & Initial

1.

1.

2.

2.

3.

3.

No No action

Opticians referred to

Notes Result of referral

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Risk – Vision 2 (Reference section 3.4)

Has the resident had a recent eye test? If under 70 years of age in the last 2 years If over 70 years of age in the last 1 year

Yes

No action

No

Action identified Date & Initial

Action completed Date & Initial

Arrange eye test as per home policies and procedures

Notes Opticians referred to Result of referral

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Risk – Neurological Impairment (Reference section 3.5) Does the resident have a neurological impairment? Yes 1. Identify & work with medical professionals to manage condition and medication. 2. Ensure procedures are in place for wandering if a problem. 3. See guidelines for Physical Activity and Mental Health & Wellbeing to implement social / physical activity.

Action identified Date & Initial

1.

Action completed Date & Initial

No

1.

2.

2.

3.

3.

Ensure patient stays as physically and socially active as possible to retain function.

Notes

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Risk – Continence (Reference section 3.6) Does the resident suffer from Urge Incontinence or Urinary Tract Infection? Yes 1. Refer to GP if the resident hasn’t been seen for the condition or for reassessment if felt necessary 2. Carry out individual risk assessments for condition 3. Consider issues for night time continence

Action identified Date & Initial

Action completed Date & Initial

1.

1.

2.

2.

No No action

Notes

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Risk – Fear of falling (Reference section 3.8) Is the resident afraid of falling?

Yes

Action identified Date & Initial

Work closely with the resident to build confidence through: Activities of daily living Increased physical activity Aids and adaptions Education Use of Hip Protector (where identified as

Action completed Date & Initial

No No Action

suitable)

Details of work done with resident

Notes

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Risk - Individual risk in taking part in activities (Reference Section 3.1) Carry out individual risk assessments for activities

RA completed for following activities

Risk assessments should be carried out positively to see what the resident can do rather than limiting their activities. Risk assessments should inform the residents care plan. Talk to residents who regularly take unsuitable risks about the possible implications of risk taking.

Notes

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Risk – Podiatry & Foot care (Reference section 3.9) Has the resident any acute issues with their foot care? Action identified Date & Initial

Yes

1) Organise for foot care in line with homes policies and procedures

1.

Action completed Date & Initial

1.

No No Action

Has the resident any long term foot care arrangements in place? Yes Can these be accommodated by the home, if not arrange foot care in line with homes policies and procedures

No Organise foot care in line with homes policies and procedures.

Foot care arrangements.

Notes 34

Risk – Podiatry (Reference section 3.9) Does the resident have suitable shoes and slippers in good condition?

Yes

Advise resident to wear appropriate foot wear whilst moving around the home.

Action completed Date & Initial

1.

No 1) Advise resident and or family on appropriate types of footwear. 2) Arrange for suitable footwear to be bought by / for resident.

Action identified Date & Initial

Action completed Date & Initial

1.

1.

2.

2.

Notes

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Risk – Alcohol and Substance misuse (Reference section 3.91) Advise the resident on the risks of falling when under the influence of drugs and alcohol and give advice on safe drinking limits as published by the Government with the understanding that these maybe lower for frailer older people. Advise resident of risks of taking non-prescribed medications.

Notes

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Risk – Use of Hip Protectors (Reference section 3.92) Does the resident currently wear a Hip Protector?

No

Yes

1) Is the resident a suitable candidate for wearing a hip protector (Consult with Doctor or Nurse)

1) Work with nursing staff to ensure compliance with wearing protector.

Yes Work with resident and GP/ Nurse around introduction of Hip Protector.

No No Action

Notes

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Risk – Are staff aware of Falls and Falls Prevention Issues (Reference section 3.93) Have all staff had training around Falls Prevention and this toolkit

Yes

1) Ensure regular updates are arranged to keep staff up to date 2) Record all staff learning 3) Staff to complete associated falls self learning questions.

Action completed Date & Initial 1) 2) 3)

No

Action completed Date & Initial

1) Arrange training through Caring for Health

1)

2) Staff to read Falls Manual

2)

Notes

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Overview of risks and interventions

Risk Falls Risk Identified Fall or Identification of Falls History in the last 12 months

Medication Psychotropic medicines 4 or more prescribed medicines Vision assessment Urinary incontinence Poor functional ability or perceived. Resident has a fear of falling At risk of osteoporotic fracture

Environmental risk

Interventions Falls Prevention Intervention Referral to Specialist Falls Service for assessment of gait, balance, mobility and muscle weakness and a targeted strength, balance and postural stability exercise prescription undertaken. Medication review Vision assessment Assessment of cognitive impairment and neurological examination Assessment of urinary incontinence Vision test Nutrition / Osteoporosis Assessment Education / Confidence building Medication review by GP or pharmacist– to be carried out regularly Use of Psychotropic medicines to be limited to absolutely necessary cases only General good management of conditions e.g. blood pressure, diabetes Residents are offered vision tests on a regular basis or if a noticeable deterioration of eyesight occurs 60-70 bi-annually 70+ annual eye checks Treatment of incontinence, bedside commodes, appropriate drug or behavioural treatments. General increase physical activity especially MSE (see Physical Activity Guidelines) and activities of daily living Specific falls related exercise prescription (if required) Appropriate aids available Education Confidence building – 1 to 1 sessions, physical activity, activities of daily living Aids available where necessary, only used initially to build confidence Promote healthy eating Supplements available where needed Nutritional assessment Weight bearing physical activity Risk assessment of physical surrounding carried out in relation to falls and acted upon Regular staff training undertaken 39

Home should have key falls link worker All Falls recorded and audited for any patterns

Alcohol / Substance misuse Neurological impairment e.g. Parkinsons, confusion, stroke

Advise on safe limits and risks, which is equivalent to no more than 2 units per days for females and 3 for males. 1 unit is equivalent to a small (125ml) glass of wine or ½ pint beer or a unit (25ml) of a spirit or fortified wine. For those who are more sensitive to the effects of alcohol, these amounts may need to be lower. Risk assessment carried out with individual and family if applicable to manage the condition and reduce falls risk.

Sedentary Lifestyle

All residents should take part in physical activity. Residents who have fallen should take part in a targeted evidenced based Falls exercise programme such as Otago, Postural Stability Course. All residents should take part in MSE training (see Physical Activity Guidance) and balance training if appropriate. All residents should take part in activities of daily living to maintain as much function as possible.

Podiatry & Footwear

Residents have access to a podiatrist and chiropodist Residents wear suitable footwear and are encouraged not to wear slippers.

Staff Training

Are all staff trained in falls awareness

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Section 5 - Introducing a Falls Prevention Policy within a care home Ideally, all care homes should produce a falls prevention and management policy which should be reviewed and updated regularly. A good falls prevention policy will already cover many of the aspects of the assessment e.g. environmental risk assessment, eye tests, and medication reviews. The policy document should ideally detail the following:-



How regularly a care home is assessing each resident’s falls risk and the format and tools that are being used for assessment.



What systems the home has in place to record and respond to or learn from falls that have occurred within the care home.



The process the home follows and the regularity that the home evaluates environmental risk factors for falls and what the mechanisms are for logging and responding to identified risks.



The actions the home takes to reduce other falls risks.



What specialist local falls support networks the home is linking into when it identifies a resident at risk of falling.



What steps the home is taking to involve residents and their carers in increasing awareness of falls risks.



What specialist and update awareness training the home is committed to offering its staff in relation to conducting falls risk assessments and organising safe and appropriate physical activity and falls prevention programmes.



Whether the home has specialist falls-prevention staff, what their qualifications are and what their role is within the home.

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Appendix 1 – Example Risk Assessment Form for Environment.

General Risk Assessment Record Form 1. Section/Service/Team……………………………………………… 2. Assessor(s)…………………………………………………… 3. Description of Task/Activity/Area/Premises etc. …………………………………………………………………………………………. What are the hazards?

Who might be harmed and how?

What are you already doing? List the control measures already in place

What is the risk rating – H, M, L? See section 5

What further action, if any, is necessary, if so what action is to be taken by whom and by when?

Action Completed State the date completed and sign.

What is the risk rating now – H, M, L? See Section 5

1.

2.

3.

4.

5.

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4. Tick (√) if any of the identified hazards relate to any of the following specific themes: Hazardous Substance

Manual Handling

Display Screen Equip

Fire

Work Equip / Machinery

Stress

Individual Person such as Young Person New/ Expectant Mother or Service User

If any are ticked a specific risk assessment form must be completed separately. For example a COSHH form must be completed if a hazardous substance is used. 5. Risk Rating The risk rating is used to prioritise the action required. Deal with those hazards that are high risk first. Risk Rating High Medium Low

Description Where harm is certain or near certain to occur and/or major injury or ill-health could result Where harm is possible to occur and/or serious injury could result e.g. off work for over 3 days Where harm is unlikely or seldom to occur and/or minor injury could result e.g. cuts, bruises, strain

Action Priority Urgent action Medium priority No action or low priority action

6. Assessment Signature of Assessor(s): Print Name: Date Assessed:

Signature of Line Manager: Print Name: Review Date:

7. Communication and Review This risk assessment should be communicated to all employees and relevant persons who may come into contact with the hazards being assessed. The assessment must be reviewed annually or following a significant change, accident or violent incident.

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Appendix 2 – Example Individual Risk Assessment.

Resident Individual Risk Assessment for Physical / Social Activity This form is designed to assist in identifying and managing risks. This form must be completed for hazards identified in relation to a person undertaking an activity. The hazards identified together with the preventative or precautionary measures must be brought to the attention of all those involved or affected by the risk. Risk Assessments are to be reviewed on a regular basis.

Name of Resident

Date of Birth

Address of Service User

HAZARD/CONDITION IDENTIFIED

Date

WHO IS AT RISK? Employees Service Users Themselves Visitors

High Medium

Members of the Public Others : Specify How Could Exposure Take Place:

When and How Often Could Exposure Occur:

HAZARD RATING

Low

Possible Consequences of Exposure:

Benefits for the Service User

METHODS USED / CONTROL MEASURES

If some of the information exists in the Care Plan, please state and give summary of control measures. If information is not contained elsewhere, give detailed information on this form of how the risk is controlled.

CONTROLS IN PLACE – Risk Rating : *if with controls in place risk rating is still high seek Health & Safety Advice

High

REMAINING PROBLEMS

Medium Low

EVALUATION PERIOD

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OUTCOME / ACTION TAKEN IN RELATION TO REMAINING PROBLEMS:

Signature of Assessor: Print Name: Signature of Line Manager : Print Name: Signature of Service User Print Name: Date Assessed: Review Date: Communication Method:

Communication of Individual Risk Assessment and Safe System of Work Signature

Print Name

Date

Designation

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Appendix 3 RECORDING THE HISTORY OF FALL(residential homes amendment)

Resident Name………………………………………………

Date……………………………………………………….Time………………………………………………………..

Where did the fall take place?…………………………………………………………………………………….

Injuries?………………………………………………………………………………………………………………….

Circumstances of fall:……………………………………………………………………………………………….

………………………………………………………………………………………………………………………………

Was the fall witnessed? Yes…… No…… Who raised the alarm?…………………………………

Does the resident recall falling? Yes…… No……

999 called? Yes…… No…… Was resident taken to A/E? Yes…… No…….

Other actions taken after the fall………………………………………………………………………………

New Falls Assessment Carried Out

yes

no

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Bibliography Managing Falls in Care Homes. Bexley Primary Care Trust and Bexley Council The Assessment and Prevention of Falls in Older People: Clinical Guidelines 21. National Institute for Clinical Excellence 2004.

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