BERKSHIRE COMMUNITY EQUIPMENT SERVICE
BED RAILS RISK ASSESSMENT GUIDANCE
This equipment guidance is intended to assist Berkshire Community Equipment Service (BCES) prescribers who are
considering the provision of bed rails, bed accessories and bed grab handles from the community equipment service,
and when completing the risk assessment form before ordering. Bed rails are sometimes also referred to as bed side
rails, bed guards, side rails, cotsides, or safety sides. Please also refer to the accompanying Bed Rails Risk Assessment
Checklist Form which can be found on IRIS/Documents/Forms
1.
Bed Types
Divans are still the most popular style of base in the UK. They are essentially an upholstered box fitted with
castors for mobility or on legs to create space beneath.
There are three main types of divan bases available:
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Sprung edge divans feature a complete open coil or pocket spring unit mounted on a frame offering
greater comfort and durability
Solid or platform tops which have a rigid non-sprung top panel offering a firmer and lower cost option
Firm edge divans generally feature a smaller number of larger heavy-duty springs within a rigid,
wooden sided frame
Slatted bases are mostly used with bedsteads. They can be rigid with no give or flexibility.
Adjustable beds are becoming increasingly popular as the bedroom becomes a multi-functional space. They
are available as singles or doubles with varying adjustable sections. The mattress is specially made so ideally
should be bought together with the bed.
Floor beds are designed to reduce the risk of falls from bed. They are often used to reduce the risk of injury
from bed rails or falling from a bed at normal height. Bed rails must not be used with this style of bed except
in extenuating circumstances. If assistance is required to assist with mobility in bed or assisting the person in
getting in and out of bed a compatible bed leaver can be used. It is important to check what height the floor
bed can raise too to ensure care can be completed safely.
2.
Bed Rails and Bumpers
The main purpose of bed rails and bumpers is to prevent a person from falling out of bed and sustaining
injury. Inappropriate use of bed rails may in itself constitute a hazard.
Two types of bed rails are available on the BCES core equipment list:
• Bed rails designed specifically for a bed by the same manufacturer and offered as an accessory
• Third party bed rails not specific to any model and intended to fit a wide range of domestic, divan or
metal framed beds from a variety of manufacturers.
3.
Bed Grab Handles
Unless otherwise specified, the term bed grab handle is used as a generic term covering all devices designed
to aid mobility in bed and whilst transferring in or out of bed, and can also be known as bed levers, bed sticks
or bed grab rails.
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Bed grab handles are designed to aid mobility in bed and when transferring in and out of bed. They are not
designed to prevent users from falling from bed or used as, or instead of, bed rails. This equipment can fit
under the mattress, clamp to the bed frame or between floor and bed.
(These definitions do not include or cover lifting poles, sometimes called monkey poles, floor fixed or wall
fixed rails and hand blocks.)
4.
Restraint
Professionals within Health and Social Care may face difficult decisions when caring for clients who, due to
their condition, may exhibit voluntary or involuntary behavior that may compromise their safety. This
includes those who fall into the following categories:
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Acutely ill and disorientated
Restless and agitated
Confused or with a cognitive impairment
Challenging behavior
The above list is not exhaustive and not all such clients will be confined to their beds. On occasions, clients
provided with bed rails may be unattended in their own home.
‘Containing’ clients within the community environment either through the use of bed rails, or other
barriers, could be considered as using a form of restraint. This must be taken into consideration when
undertaking the risk assessment.
Any form of restraint should only be considered as a last resort for the following reasons:
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Every citizen who is not subject to legal detention has the right to be free from the use of
unauthorized force to restrict his movement. Applying a restraint to anyone, whatever the mental or
physical condition, may be construed as a denial of this basic human right.
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Professionals within health and social care must at all time ‘act always in such a manner as to
promote and safeguard the interests and well-being of clients’.
When considering the use of bed rails they may encounter the dilemma of ensuring that the client
comes to no harm versus the need to respect the client’s basic rights. The scope of these guidelines
acknowledges that bed rails are sometimes required to protect the client from harm but that they
should not be used to cover a deficiency of service, or a lack of professional skill in caring for such
clients.
The decision to supply bed rails should be in the best interest of the client. The practitioner must undertake
an individual risk assessment that will inform their decision making in the provision of bed rails.
5.
Consent and mental capacity
Decisions about bed rails need to be made in the same way as decisions about other aspects of treatment and
care.
This means:
• The client should be included in the decision making processes if they have mental capacity to do
so.
• Capacity is the ability to understand and weigh up the risks and benefits of bed rails once these
have been explained to the service user.
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Colleagues can learn about the client’s likes, dislikes and normal behaviour from relatives and
carers, and should discuss the benefits and risks with relatives or carers. However, relatives or
carers cannot make decisions for adult clients (except in certain circumstances where they hold a
Lasting Power of Attorney extending to healthcare decisions under the Mental Capacity Act
2005).
If the client lacks capacity, (as demonstrated by Mental Capacity Assessment), colleagues have a duty of care
and must decide if bed rails are in the client’s best interests, using the bed rail decision assisting tool as part of
the best interest assessment.
6.
Roles and Responsibilities
Service and team managers will ensure that all staff in their sphere of management who risk assess, and
prescribe the use of bed rails are competent to do so and that bed rails are maintained and used in
accordance with these guidelines and the manufacturer’s recommendations.
Practitioners prescribing bed rails are professionally accountable for ensuring that:
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7.
They are up to date with their bed rails training
They are familiar with the different models of bed rails, and how these affect safety and function
They have a working knowledge of alternative solutions to bed rails
They have the ability to recognize, identify and resolve problems including badly fitted bed rails
They are familiar with safe installation of bed rails in line with manufacturer’s instructions
They have the ability to demonstrate to the patient/carer how to use bed rails safely
They complete a risk assessment which is documented and uploaded to their clinical records
Following installation they check the appropriate bed rails have been provided with bumpers
Appropriate guidance has been given to the user and/or carers
A visual inspection of the bed rails is undertaken every time they are used and, should any
equipment fault be identified, the equipment is not used and appropriate action for
repair/replacement is instigated immediately
That a collection is raised with NRS when bed rails no longer required by the client
Any near misses, incidents and accidents that occur as a result of using bed rails are reported as a
clinical risk using the correct incident reporting procedure for their organisation, and in addition are
reported to the BCES Lead Commissioner
Any near misses, incidents and accidents that occur as a result of NOT using bed rails, when their use
would have been appropriate, are reported using the organisation’s incident reporting procedure
Risk Assessment
A risk assessment should be carried out to determine if bed rails are required to protect the client from harm.
Where possible, this should include discussion with the client and their relatives/carers
The Bed Rails Risk Assessment Checklist Form (separate document) can be used to record the assessment, or
the organisation’s own risk assessment. This form can also be found on IRIS/Document/Forms.
The decision making flowchart (Appendix 1), and the chart below provide guidance.
BCES- Last updated 21/04/2023
When are bed rails appropriate?
Bed rails and bed rail bumpers may be used for certain people who, through the risk assessment process,
have been identified as being at risk from falling out of bed. These may include:
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Acutely ill and disorientated people
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Restless and agitated people
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Confused or impaired memory such as those with a diagnosis of dementia
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People with challenging behaviour
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The person requests them
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The person has difficulty maintaining/regaining a comfortable position in bed and, should they feel at
risk from falling, a single support gives them confidence
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Where no other alternative will suffice
It should not be assumed that practitioners can remove all risks to people whose freedom they must respect
and protect. A person with capacity to consent may request bed rails to enhance their feeling of security. The
person’s choice should be acknowledged and included in the risk assessment or care plan.
When are bed rails inappropriate?
Bed rails and bed rail bumpers may be inappropriate in the following circumstances:
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People who attempt to climb out of bed
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People whose agitation is made worse by such confinement
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People whose behaviour puts them at risk from becoming trapped in the bed rails
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People at risk of injury due to involuntary movements
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People who would be independent if the bedrails were not in place
In addition:
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Incorrect use of bed rails or bumpers can constitute a hazard and introduce entrapment risks.
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Bed rails are not designed as a mobility aid and appropriate equipment should be installed to facilitate
this – e.g. handling pole, bed sticks or bed levers.
When completing a risk assessment take into consideration:
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Environmental constraints
Clients wishes
Clients capacity
Suitability of existing bed for fitting accessories
Condition and type of mattress e.g. extra dense foam
Falls related to transfers
Informal carers and family members understanding how to use equipment correctly and safely
Alternatives to bed rails
Whether the benefits outweigh the risks
Risk of entrapment
Occupancy dynamics should be taken into consideration and if any of the following apply then the bed rails
should not be used and an alternative solution sought.
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Is the client’s head or body small enough to pass through the bars of the bed rails?
Is the client’s head, or body, small enough to pass through the gap between the lower bed rail bar
and the mattress, when the mattress is compressed at its edge by their weight?
Does the client have any impediment (i.e. sensory, disease) which could result in increased risk of
entrapment?
If bed rails are in situ ensure avoid:
• Gaps of over 60mm between the end of the bed rail and the headboard which could be sufficient to
cause neck entrapment.
• Gaps of over 120mm from any accessible opening between the bed rail and mattress platform
Side wedges can be used to help fill the gap between mattress and rail, however, if the mattress is particularly
soft this may not be fully effective.
BCES- Last updated 21/04/2023
Bed rail bumpers
Bumpers are primarily used for preventing impact injuries, but in some instances they can reduce the
potential for entrapment.
However, bumpers can increase the risk of entrapment or suffocation. Therefore it is important to consider
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Client diagnosis, behaviour, cognitive state, or medication régime
Gap between bumper and mattress
Movement in bed
Repetitive and voluntary movements
Choice
Consent
Compatibility of equipment
Ensure all equipment being placed in situ is compatible with one another e.g. mattress systems/mattress
elevator/pillow lifter/mobile hoist/standing hoist
Consideration should be given to the type of mattress in use, especially when using air mattresses or overlays
with bed rails for the following reasons:
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If an air mattress is to be used in conjunction with a base foam mattress advice should be sought on
the suitability of the combination. If a bed rail is installed this combination can reduce the height of
the bed rail, relative to the top of the mattress, which may allow the occupant to roll over the top of
the bed rail.
The hazard of entrapment between the side face of the mattress and the bed rails may be
exacerbated due to the soft, easily compressible nature of the mattress edge.
Many divan bed rails rely on the weight of the traditional divan mattress to hold the assembly
securely in place. If the standard mattress is replaced with an air mattress, or lightweight foam
mattress, the whole bed rail assembly including the mattress and bed occupant can tip off the bed
when the occupant rolls against the bed rails.
Vigilance is required when determining bed rails for the diverse range of beds used in the community
environment. For example, bed rails that have been designed for use with a divan bed will be of a
BCES- Last updated 21/04/2023
fairly universal design. They are not necessarily tailored for a specific divan bed with exact base and
mattress dimensions or specific mattress density and should not be used for a hospital profiling bed.
Using bed rails with children
An individual risk assessment should always be carried out on the suitability of the bed rail for a child or small
adult and reference should be made to manufacturers' guidance.
Most bed rails are to be used only with people over the age of twelve / adults over 1.5m in height. However, a
risk assessment must always be carried out on the suitability of the bed rail for the individual child or small
adult, as bar spacing may need to be smaller.
See Appendix 2 for more information.
Recording
Once the risk assessment has been completed, it should be clearly documented in the client’s care plan.
This can be done using the Bed Rails Risk Assessment Tool in this document or your own organisation’s risk
assessment tool.
Risk assessments should be carried out before use and then reviewed and recorded after each significant
change in the bed occupant's condition, replacement of any part of the equipment combination and
regularly during its period of use, according to local policy.
It should be noted that the bed rails risk assessment is not a stand-alone document but is part of the whole
risk assessment process for your client.
Where possible clients and their carers should be offered an information leaflet
8.
Alternatives to bed rails
Alternative methods can be used to reduce a person’s confusion by re-orientating them to/or altering and
controlling the environment. This will need to involve the participation of formal/informal carers.
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Move person to a more observable area to maximise supervision.
Use of bed sensor and / or position device.
Use of high-low bed.
Use of soft cushioning on the floor to break a client’s fall, such as crash mat. Crash mats may
introduce client manual handling risks.
Ensure bed returned to lowest height after care delivery.
Ensure client’s needs are anticipated, such as accessible drinks, regular toileting, call bell to hand.
Increased monitoring of clients at high risk of falls.
Reablement/ rehabilitation
Where can I get advice?
If you are unsure on any aspect relating to the bed rails risk assessment or which product to choose please
speak firstly to a senior colleague in your organization who may be able to help.
You can also speak to the NRS Clinical Team
NRS Clinical Team
0118 903 2410
clinical@berkshire.nrs-uk.net
BCES- Last updated 21/04/2023
10.
Adverse event reporting
Serious injury can result from the incorrect use of bed rails where they are inappropriate for the user, do not
match the type of bed and mattress, and are not checked, maintained and reviewed.
If there is any apparent hazard the bed rail must not be used
If a bed rail is faulty, it must not be used.
Immediately inform NRS Healthcare on 0344 893 6960 and arrange for a replacement set of bed rails to be
delivered that day.
Should any injury or near miss occur to any individual, an incident report should be completed in accordance
with your organisation’s policy, and where community equipment has been used an additional copy sent to:
The BCES Lead Commissioner – raymond.marshall1@westberks.gov.uk
NRS Healthcare Service Manager – pcallaway@nrshealthcare.co.uk
11.
Assessment following installation of bed rails
Prior to delivery bed rails will be cleaning and checked to ensure they are in working order.
During delivery the drivers will ensure the bed rails have been fitted according to the manufacturers guidance.
If the drivers are unable to fit the bed rails as they are incompatible with the bed the prescriber will be notified.
Following installation of bed rails the following safety checks must be undertaken, ensuring;
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They are compatible to the bed and mattress, and that they do not present a hazard of entrapment
to the patient
The manufacturer‘s guidelines are delivered with the bed rails if needed
They are not bed sticks. (Bed sticks are only used for transfers in and out of bed)
The weight of the patient does not exceed the recommended weight limit of the bed rail
The gaps between the end of the bed rails and headboard/wall will not allow for entrapment
The spacing between bars is the appropriate size to prevent head or limb entrapment
The mattress does not compress easily at its edges so that an entrapment hazard may be created.
There are no gaps between the lower bar of the bed rail and the top of the mattress that can cause
entrapment
The dimensions and overall height of the mattress does not compromise the safety of the bed rails
The bed rails are a horizontal, not vertical design (upright)
Only paediatric bed rails are used in the paediatric setting, as these have bar spaces designed
specifically for children
Bed bumpers are provided at all times, unless highlighted via the risk assessment process that they
are unsuitable
Follow up visits will be required to monitor and review the provision of bed rails and update the risk
assessment. The frequency of these reviews should be in line with the local organisation’s guidance and
clinical need/change in client condition. Any changes should be documented.
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Appendix 1
BED RAIL RISK ASSESSMENT FLOW CHART
Complete on initial assessment
Review if condition changes
Review in preparation for discharge
Patient Need
Has the patient/service user slipped,
rolled or slid out of bed?
Is the patient/service user at risk of
slipping, rolling, sliding or falling out of
bed?
Patient Request
START HERE
BED RAILS NOT
REQUIRED
NO
NO
Does the patient/service user wish
to use bed rails when the risk of
rolling, sliding or slipping out of
bed is not apparent?
YES
YES
NO
Does the patient / service user
have capacity to make the decision
to use the bedrail?
YES
NO
Has an individual risk assessment
been agreed with the patient /
service user? (see Mitigation of
Risk)
YES
YELLOW
GREEN
MANUAL HANDLING ASSESSMENT
Is the patient/service user safe to get out
of bed unsupervised?
RED
YES
NO
Is the patient/service user capable of
climbing over bed rails?
YES
NO
Does the patient/service user have
sensory or cognitive impairment/
confusion/delirium/dementia?
NO
DECISION TO USE BEDRAILS
BCES- Last updated 21/04/2023
USE BEDRAILS WITH
CAUTION
Document individual’s
needs in Care Plan
Mitigation of Risks
Risk assessments must document:
➢ Ensure access to carer to lower bedrails prior to
getting out of bed
➢ Patient is aware of risks associated with use of
bedrails
➢ Method of alerting carer for assistance to get out of
bed
➢ Length of time unsupervised and associated risks
➢ Environment is considered suitable for bedrails.
YES
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NO
Does the patient/service user decline to
consent to use of bedrails?
CONSIDER
ALTERNATIVES
YES
REASSESSMENT
Minimum – weekly in Hospital setting
As patient’s conditions change
If changes to the patient equipment occurs
STOP ASSESSMENT
Document and record in Care Plan
BEST INTEREST DECISION e.g. may
be most appropriate. Document and
record in care plan.
COMPLETE
ASSESSMENT
PROCESS
AGAIN
Appendix 2
Bed rail dimensions in BS EN 50637: 2017 – requirements for children
Diagram
Reference
A1
BS EN
50637:2017
<60mm
A2
<60mm
A3
<60mm
A4
<60mm
Partially enclosed opening between segmented or
split side rail and the mattress support
A5
<60mm
Partially enclosed opening defined by lowest point
of a side rail, the adjacent side rail support and
mattress support platform, to the outside of the
side rail supports
Other openings defined by accessories (e.g. IV
poles, fracture frames) and side rails, head or foot
boards and or mattress support platform. Not
shown in figures.
Distance between mattress support platform and
the lowest point of the side rail outside the side
rail support.
AND
The angle between the side rail and mattress
support platform at the range of the mattress
height defined by the manufacturer ± 2 cm.
A6
<60mm
A
<60mm
B
Gap between head board and adjacent side rail
C1
<40mm
AND
Angle between
mattress
support
platform and
side rail
interface >75°
over the entire
range of
mattress
heights from
minimum
recommended
height minus 2
cm to the
maximum
recommended
mattress
height plus 2
cm.
<40mm
Gap between segmented or split side rails with
both side rails raised
C2
Description
Fully enclosed openings within a side rail,
head/foot board, mattress support platform
Fully enclosed opening defined by the side rail, its
supports and the mattress support platform
Partially enclosed opening defined by the head
board, mattress support platform and side rail
Partially enclosed opening defined by the foot
board, mattress support platform and side rail
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<40mm
OR
>300mm
Notes
Except when gap
between side rail and
foot board is >300mm
Except when gap
between side rails is
>300mm
For a gap >300mm: the
gap shall be >300mm or
<400mm for the entire
vertical distance
Description
For all medical beds except junior beds: gap
between side rail and foot board. Other openings
defined by accessories (e.g. IV poles, fracture
frames etc.) and side rails, head board, foot board,
and or mattress platform
For junior beds: gap between side rail and foot
board. Other openings defined by accessories (e.g.
IV poles, fracture frames etc.) and side rails, head
board, foot board, and or mattress platform
Region defined by side rail/head board/foot board
and the mattress for cribs and cots
Region defined by the side rail/head/foot board
and the mattress for junior beds and oversize cots
Diagram
Reference
C3
BS EN
50637:2017
<40mm
C4
<40mm
OR
>300mm
D1
Perform test
D2
Perform test
OR
Gap between
side
rail/head/foot
board and
mattress
<30mm
For diagram see next page
BCES 2021
Notes
For a gap >300mm: the
gap shall be >300mm or
<400mm for the entire
vertical distance
Cone tool does not sink
below the mattress
surface by 50% or more
of its 60mm diameter.
Cone tool does not sink
below the mattress
surface by 50% or more
of its 60mm diameter.
BCES 2021