DEPARTMENT OF HEALTH EAST MIDLANDS
GUIDANCE ON BEST PRACTICE IN CARE HOMES
FOR THE PREVENTION & REDUCTION OF FALLS
& FRACTURES–
for commissioners and providers of services of both social
care managed homes and independent sector homes
November 2010
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
Contents
PAGE
…………………........................................................... 3
1.
INTRODUCTION
2.
BACKGROUND ………………………………………………………………… 3
3.
PROVIDERS OF SERVICES …………………………………………………. 5
3a) MANAGEMENT OF POLICIES & PRACTICES ………………………... 6
3b) SUPPORT FOR RESIDENTS ……………………………………….…… 7
.
3c) IMPROVING THE ENVIRONMENT ……………………………………… 8
4.
COMMISSIONERS OF SERVICE ……………………………………………. 8
5.
CONCLUSION ………………………………………………………………….. 9
6.
APPENDICES
PROVIDER CHECK LIST Appendix1……………………............................. 10
KEY POINTS FOR COMMISSIONERS Appendix 2………………………... 11
7.
REFERENCES………………………………………………………………….. 12
8
ADDITIONAL INFORMATION SOURCES……………………………………12
Note:
The term ‘care home’ includes residential care homes, nursing homes and intermediate care
facilities
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
1. Introduction
The significance of reducing the incidence of falls, which result in serious injury and promoting
bone health in the older population was highlighted in Standard 6 of the National Service
Framework for Older People 20011. There has been much research and countless papers
written on the prevention and management of falls & fractures and effective interventions in
Health & Social Care. The common theme being that no one intervention is effective in
reducing falls, but multi-factorial interventions have the most significant outcomes. In July 2009
the Department of Health launched The Prevention Package for Older People 6, this comprises
of a suite of resources designed to support Primary Care Trusts, Strategic Health Authorities
and Local Authorities in prioritising and effectively commissioning services that support the
health, well-being and independence of older people
2. Background
NHS East Midlands has identified Falls Prevention and Bone Health as a QIPP (Quality,
Innovation, Productivity & Prevention) priority. This is a regionally led and co-ordinated
workstream with the aim of improving patient outcomes and efficiency of care after falls and
fractures through compliance with core standards, by implementing best practice tariff for hip
fractures and responding to the first fracture and preventing the second, early intervention to
restore independence, preventing frailty and promoting bone health and reducing accidents.
Falls of older people in hospitals and other care settings is an important area where
appropriate systems and awareness can reduce risk6
This guide has been produced for use by Local Authorities to compliment the Falls and Bone
Health QIPP programme of work when commissioning Care Home Placements and also as a
guide for providers of care to help them to meet the standards and outcomes that
commissioners will be expecting.
It is recognised that older people who live in residential and nursing care homes are at
particular risk of falling. Research shows that in care homes:
o the rate of falls is almost three times that of older people living in the community
o 25% of older people who live in care homes suffer serious injuries as a result of falling
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
o 40% of hospital admissions from care homes follow a fall
o Repeated falls and instability are very common precipitators of nursing home admission
Section 7.3 of the National Minimum Standards Care Homes Regulations, Care Standards Act
2000 2 stated :
‘The service user’s plan meets relevant clinical guidelines produced by the relevant
professional bodies concerned with the care of older people, and includes a risk assessment,
with particular attention to prevention of falls.’
With effect from 1 October 2010 The Care Standards Act has been superseded by the Health
& Social Care Act – Essential standards of quality and safety. These essential standards of
quality and safety consist of 28 regulations that are set out in two pieces of legislation: the
Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 3 and the Care Quality
Commission (Registration) Regulations 20094
For each regulation, there is an associated outcome9 – the experiences people are expected to
have as a result of the care they receive
Some of the evidence that providers used to demonstrate they met the old standards can be
used for the new standards.
It is important, however, that providers begin to develop new systems which show how they:
o deliver positive outcomes for people who use services;
o capture information about how people experience the services they provide
Registered Care Home Managers are responsible for managing the risks and the effects of
falls in care homes. The regulations and outcomes do not make any specific reference to the
prevention of falls so this paper gives an overview of measures that can be taken by care
home providers to manage the risk of falls, and information that commissioners should
consider when commissioning services from them.
Residents will need to agree any suggested risk minimising actions. Consideration needs to be
given to issues of capacity and decision making ability; cognitive impairment should not be
seen as a barrier to taking action to reduce the risk of falls and fractures.
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
3. Providers of services
Facts
o Falls cause older people anxiety, injury and disability
o Fear of falling reduces quality of life and well-being
o Certain medications and more than four types of medications increases the risk of falls
o Limited physical activity decreases muscle strength and affects balance, making falls
and injuries more likely
o Care home residents are likely to be frailer and have medical conditions such as stroke,
Parkinson’s Disease or dementia or have sensory impairments that increase the risk of
falling
o Emergency action after a fall in care homes diverts staff from pre-planned care
Early in 2004, Help the Aged collected examples of how care homes were reducing falls and
their effects5 The following paragraphs give a brief explanation of their findings, for more
detailed information see the document which can be accessed on the website:
http://www.housingcare.org/downloads/kbase/2312.pdf
There were three interrelated areas of action:
o
Management: policies and practices
o
Support for residents
o
Improving the environment
Success was achieved with a combination of activities. Evidence is emerging that a holistic
approach-encompassing resident, staff and institutional factors can be successful
8.
The Department of Health Prevention Package for Older People Falls & Fractures – Effective
interventions in health & social care6 also made reference to the key messages to maximise
the impact of lifestyle advice relevant to preventing falls are:
o focus on improving strength and balance, not falls
o encourage people to personally choose the advice and activities that suit them
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
o don’t focus on avoiding ‘hazards’ or physical restriction such as wearing hip protectors –
this is perceived as overbearing
Within this context the headline messages for older people, family and carers are that :
o falls are a risk as you get older, but not inevitable
o staying active and dealing pro-actively with any long-term condition will reduce frailty
and preserve independence
o if you are getting unsteady, seek advise so underlying factors, such as eyesight,
medications, nutrition, strength and balance, can be addressed
3a. Management of Policies and Practices
To reduce falls in homes managers need to take action in order to manage resources
effectively, comply with the Health & Social Care Act essential standards of quality and safety
and recommended policy frameworks, and follow good practice in order to improve life for
residents. See Provider Check List Appendix 1.
This should involve:
Assessment
All residents should be assessed for their risk of falls, particularly new residents, and those
who are known to have had previous falls. These assessments provide a foundation for
detailed care plans, targeted action to reduce the individual’s risks, and improved access to
specialist resources such as Falls clinics, Falls co-ordinators, Specialist nurses etc
There are many examples of Falls Risk Assessment Tools (FRATs) and the NICE Falls clinical
guidelines 217 recommend tests that are easy to administer. Homes can seek advice on
implementation from their local falls services. The assessments should be regularly reviewed
(6 weeks after admission, after any significant change in functioning and annually as a
minimum).
Training and awareness
Training and awareness sessions for staff can be accessed from many different sources, a
good starting point being local primary care falls services which can either deliver training or
give advice on what is available. The aim should be to raise staff awareness, and that the
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
reduction of falls becomes embodied in holistic care rather than just an add-on to everyday
practice.
Falls records and audits
The maintenance of falls records and audits can identify patterns around the circumstances of
falls, which can then inform appropriate actions to reduce the incidence of falls. The reporting
procedure also raises and maintains staff awareness of the risks and the need for vigilance in
this sensitive area of management.
3b. Support for residents
Alongside supporting staff to reduce the risk of falls there should be support for the residents.
Raising residents’ awareness to reduce their risks and maintain their mobility, wherever
possible, helps to raise their confidence and help them understand what may cause them to
fall.
This support can take many forms some of which are listed below:
Exercise and activity: the promotion of exercise improves balance, strength and mobility –
appropriate to the resident’s abilities ranging from fully mobile to chair based activity
Increasing bone density: reduces the risk of fracture, homes should ensure nutritional
assessment of diet and support compliance with GP prescriptions
Reducing the impact of falls: to minimise the risk of injury some care homes offer hip
protectors to residents at high risk of falls. Although the effectiveness of hip protectors has not
been proven in all settings, some homes report success in reducing the risk of fractures
Vision: care homes can reduce the risks associated with visual impairment by raising staff
awareness and assisting with spectacle usage and maintenance
Foot care and foot wear: homes can introduce a range of measures to advise on footwear,
walking aids and facilitate regular visits by chiropodists, podiatrists
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
Clothing and dressing: by working with occupational therapists to find aids and adaptations
that will, help residents to dress themselves safely, and raise awareness of trip risks
associated with long/loose fitting clothing
Information: by using a range of materials to advise residents, their families and friends about
how the risk of falling can be reduced
3c. Improving the environment
All homes have been subject to National Minimum requirements with regard to a safe
environment. Those homes that specifically assess environmental risks reduce falls through
targeted actions. e.g in addition to physical hazards - lighting, colour schemes, patterns on
carpets etc
4. Commissioners of services
Effective interventions in health and social care for the prevention of falls and fractures 6 states
that a falls care pathway commissioned by health and social care from a multi-agency team
should form the basis of interventions in the community. Developing the pathway can help
commissioners to make local decisions about what they want from each sector.
Commissioners of NHS and social care services should include references to falls prevention
in service specifications and incorporate it as a key quality indicator or outcome in monitoring
provider services.
Although there is insufficient evidence to either recommend for or against multi-factorial or
multi-component interventions in long term care
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commissioners should check what ‘best
practice’ interventions are practiced when commissioning residential/nursing care (Appendix 2)
to ensure there is consistency and quality of services commissioned.
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
5. Conclusion
Experience suggests that falls can be reduced by 50% when an individual’s risks of falling are
assessed and action taken to reduce those risks. There is no single or best approach to
reducing falls, but by implementing a combination of
o best practice,
o observing guidance and regulations and
o working in partnership with their local Health Services and Local Authorities as an
integral part of a multi – agency care pathway
care homes can access support and obtain advice for managing this complex issue.
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
APPENDICES
APPENDIX 1
PROVIDER CHECK LIST
As a provider of care in either nursing or residential care homes the Registered Care Home
Manager is responsible for managing the risks and effects of falls in their home. By
implementing the following actions the risks and effects of falls can be significantly reduced
and the outcomes improve the life of residents.
Tick those actions that the home currently practices
1. MANAGEMENT OF POLICIES & PRACTICES
ASSESSMENT – all new and existing residents regularly assessed for
their risk of falling
TRAINING & AWARENESS – awareness training for staff to embed the
reduction of falls into holistic care
FALLS RECORDS & AUDITS – maintain falls records & audits
√
□
□
□
2. SUPPORT FOR RESIDENTS
EXERCISE & ACTIVITY – promotion of appropriate exercise
□
INCREASING BONE DENSITY – nutritional assessment of diet and
compliance with GP prescriptions
□
REDUCE THE IMPACT OF FALLS – appropriate provision of hip protectors
□
VISION – assistance with spectacle usage and maintenance
□
FOOTCARE & FOOTWEAR – advice on footwear & walking aids & facilitate
chiropody & podiatry visits
□
CLOTHING & DRESSING – assistance with dressing
awareness of risks with ill fitting clothing
safely and raise
□
INFORMATION – advice on the risk of falling and how those risks can be
reduced
□
3. IMPROVING THE ENVIRONMENT
NATIONAL MINIMUM REQUIREMENTS FOR A SAFE ENVIRONMENT compliance
□
ENVIRONMENTAL ASSESSMENT – specifically assess environmental risks
to reduce falls
□
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
APPENDIX 2
KEY POINTS FOR COMMISSIONERS
Commissioners should check the following key points in relation to Falls and Bone Health
when commissioning services from care homes, the Provider Check List at appendix 1 is
designed to help providers fulfil the expectations of these key commissioning requirements.
Falls
prevention
strategy in
place
Links with
primary,
ccommunity,
secondary
health care
Systems to
monitor &
learn from
falls
CARE
HOME
Support for
residents
Environmental
assessments
Screening
process to
identify
residents at
risk
Training &
ongoing
awareness
for staff
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Department of Health East Midlands - Guidance on best practice in care homes for the prevention & reduction
of falls & fractures
References
1. National Service Framework for Older people Department of Health 2001
2. National Minimum Standards Care Homes Regulations 3rd Edition 2006 The Care
Standards Act of 20002
3. The Health & social Care Act 2008 (Regulated Activities) Regulations 2010
4. Care Quality Commission (Registration) Regulations 2009
5. Preventing falls ; Managing the risk and effect of falls among older people in care
homes Help the Aged May 2004
6. Prevention package for older people – Falls & fractures effective interventions in health
& social care DH 2009
7. National Institute for Clinical Excellence (2004). Falls: the assessment and prevention of
falls in older people Clinical Guidance 21
8. Magaziner J, Miller R, Resnick B. Intervening to Prevent Falls and Fractures in Nursing
Homes: Are We Putting the Cart Before the Horse? Journal of the American Geriatrics
Society 2007; 55:464-466.
9. CQC Quick guide to the essential standards
www.cqc.org.uk/db/documents/Quickguidetotheessentialstandards
10. Clinical Practice Guidelines for the Prevention & Management of Falls in Older Persons
2008
Additional information sources
o Example Guide to Assessment & Intervention – Falls & Fracture Prevention in Nursing
& Residential Homes – Berkshire East Community Health services
o
Falls: the assessment and prevention of falls in older people Understanding NICE
guidance-information for older people, their families & carers
o British Geriatrics Society Best practice Guides – Falls
o Activity Provision Benchmarking good practice in care homes – College of Occupational
therapists
o SCIE research briefing 1:Preventing falls in care homes
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