INPATIENT FALLS MANAGEMENT POLICY
POLICY NUMBER:
INPATIENT FALL MANAGEMENT POLICY
Document History
Version Date:
April 2011
Version Number:
1
Status:
Next Revision
Due:
Developed by:
Approved
Policy Sponsor:
Pathways & Clinical Outcome Manager
EQIA completed:
Dec 2010
Approved by:
Quality committee
Date approved:
11th April 2011
April 2013
Falls Implementation Group
Revision History
Version
Revision
date
Summary of Changes
To support inclusive access of this policy (guideline etc), it has been left-aligned and is
available in alternative formats. To obtain a copy of the policy in large print, audio, Braille
(or other format) please contact Communications team, by Tel: 01773 525099 or email
communications@derbyshirecountypct.nhs.uk
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INPATIENT FALLS MANAGEMENT POLICY
TABLE OF CONTENTS
1.
FULL DETAIL OF POLICY .......................................................................................... 3
1.1
Hospital Admissions ............................................................................................... 3
1.2
Training and development for falls prevention and management ...................... 4
2.
References and Associated Documentation ............................................................ 4
3.
Appendices ................................................................................................................. 6
Appendix 1
APPENDIX 2
Falls prevention in hospitals Flow chart................................................. 7
PATIENT FALL FLOW CHART .............................................................. 8
appendix 3 .......................................................................................................................... 9
appendix 4 ........................................................................................................................ 11
appendix 5 ........................................................................................................................ 13
appendix 6 ........................................................................................................................ 15
4. AIM .............................................................................................................................. 17
5.
5.1
6.
Background ............................................................................................................... 17
Table - Objectives ................................................................................................ 17
Area for Implementation .......................................................................................... 18
7. Organisational Accountability/Responsibilities i.e. CEO, Directors, Managers,
Staff ................................................................................................................................... 18
8.
Intended Users .......................................................................................................... 18
9.
Definition ................................................................................................................... 19
10.
Indications for Use ................................................................................................ 19
11.
Contra-indications ................................................................................................ 19
12.
Equality Impact Statement ................................................................................... 19
13.
Monitoring and Performance Management of the policy .................................. 19
14.
Support and Additional Contacts ........................................................................ 20
Equality & Diversity Impact Assessment :
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Level I Screening .................................. 21
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INPATIENT FALLS MANAGEMENT POLICY
INPATIENT FALLS MANAGEMENT POLICY
1.
FULL DETAIL OF POLICY
This policy is to assist staff to reduce the risk, incidence and severity of in-patient falls
within the Community Hospitals of Derbyshire Community Health Services (DCHS). The
policy should be read in conjunction with the policies for The Management and Prevention
of Slips, Trips and Falls and the Safe and Effective use of Bedrails in Community
Hospitals. Clinical Policies page
1.1
HOSPITAL ADMISSIONS
All clinical staff working in DCHS community hospitals must follow the ‘Falls Prevention in
Hospitals’ Flow chart (see Appendix 1).
1.1.a Risk Assessment
Patients admitted to a DCHS community Hospital require a Falls Risk Assessment
completing within 4 hours of admission ‘Risk assessment for the Prevention and
Management of Falls’
1.1.b Treatment Plan
A treatment plan reflecting each individual’s falls risk assessment will be generated,
identifying the goals, interventions and risks agreed with the patient and their carers if and
when appropriate. This should be completed within 24 hours of admission. Please click
on the link to access the documentation site for ‘high’ 0310, ‘medium’ 0309 and ‘low’ 0308
treatment plan templates
1.1.c Evaluation and Reassessment
The frequency of review of the Falls Risk Assessment must be documented and
undertaken (see ‘Risk assessment for the Prevention and management of Falls’). The risk
of falls will be reassessed in accordance with each individual’s risk assessment – ‘high’ daily, ‘medium’ – every 4 days and ‘low’ – every 7 days, (therefore at a minimum of every
7 days), or if any changes occur. The treatment plan will be updated following each
reassessment of falls risk, (changing to relevant treatment plan if appropriate), and the
patient’s records updated.
1.1.d Fall
If a patient falls or a fall related near miss occurs, the ‘Patient Fall Flow Chart’ will be
followed and actioned, see Appendix 2.
IF A SEVERE INJURY IS EVIDENT OR SUSPECTED DIAL 9 999 FOR TRANSFER TO
ACUTE SERVICES.
All incidents must be reported including patient details, time, location and circumstances of
the falls, and details of any injury or if non apparent, by completing an Incident Form.
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All incidents which have level 3 or 4 harm will be evaluated using root cause analysis by
the Patient Safety Team.
1.1.e Discharge to Own Home
Patients at risk of falls at home needs to be established. Refer to Community Falls
Management Policy Section 1.1a, 1.1b screening and risk assessment tools.
Referrals onto community or day service based specialist falls services for specialist falls
interventions will be made if indicated.
1.1.f Discharge to Care Home
Patients at risk of falls in care home settings need to be established. Refer to Community
Falls Management Policy Section 1.1a, 1.1b screening and risk assessment tools.
Referral onto community falls service will be made if indicated by multi-disciplinary team.
1.2
TRAINING AND DEVELOPMENT FOR FALLS PREVENTION AND
MANAGEMENT
Within DCHS there will be 3 levels of training for falls prevention and management:
Level 1 - ALL DCHS staff regardless of location, should have basic awareness training in
relation to falls prevention and their roles and responsibilities therein. This will include an
understanding of the potential causes of falls including intrinsic and extrinsic factors.
All DCHS staff assessing patients, again regardless of location, will be made aware of and
trained in the use of the relevant falls prevention and management tools and associated
processes. They will also undertake further fall prevention and management training on
areas relevant to their profession.
All Level 1 staff will access the Falls Training DVD and line managers must keep a record
of the staff who have undertaken this training and forward the details to the Learning Team
to ensure the electronic staff record (ESR) is updated. Falls Awareness and Prevention will
be included in essential training, all new staff induction and preceptorship competency
frameworks.
Level 2 - All wards/ departments should have an identified ‘Falls Champion’ who will be
expected to lead and ensure the process is in line with the policy and to lead the local
scrutiny of monthly falls reports. Identified champions and other key clinical leaders will
receive training on the falls policy, risk assessments decision algorithms.
Level 3 - All staff providing a specialist falls service or performing specialist falls
assessments will require evidence based training and skills updating. This training will
require individuals to access ‘learning beyond registration’ funding to apply for accredited
courses delivered by external providers.
2.
REFERENCES AND ASSOCIATED DOCUMENTATION
DCHS Management and Prevention of Slips, Trips and Falls Policy
DCHS Record Keeping Policy
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DCHS Incident reporting Policy
DCHS Joint Derby and Derbyshire Health & Social Care Policy for the Safe Use of Bed
Rails in the Community.
DCHS Policy for the Safe and Effective Use of Bed Rails within the Community Hospital
Do Once Share Pathway web site accessed November 2010:
http://www.connectingforhealth.nhs.uk/resources/systserv/do-onceand/?searchterm=do%20once%20and%20share
Fonda D et al. (2006) Reducing serious fall related injuries in hospital. Medical Journal of
Australia 184: 379-382
Haines TP et al (2004) Effectiveness of targeted falls prevention programmes in a sub
acute setting. A randomised controlled trial. British Medical Journal 328: 676-679
Healey F et al. (2004) Using targeted risk factor reduction to prevent falls in older hospital
inpatients A randomised controlled trial Age and Ageing 33: 390-395
Help the aged (2008) Falling Short Help the Aged London
NHS Institute for Innovation and Improvement (2009) High Impact actions for Nursing and
Midwifery
http://www.institute.nhs.uk/images/stories/Building_Capability/HIA/NHSI%20High%20Impa
ct%20Actions.pdf
National Institute for Health and Clinical Excellence (2004) Falls-The assessment and
prevention of falls in older people. Available at:
www.nice.org.uk/guidance/CG21/guidance/pdf/English
Department of Health (2001) National Service Framework for Older People
Medicines and Healthcare products Regulatory Agency Device Alert 2007/001. Reporting
Medical Device Adverse Incidents and Disseminating Medical Device Alerts. Available at:
www.mhra.gov.uk
Oliver D et al. (2005) Prevention of falls in hospitals and care homes and in persons in
those settings with cognitive impairment or dementia. Department of Health Accidental
Injury Prevention Programme
Oliver D et al. (1997) Development and evaluation of evidence based risk assessment tool
(STRATIFY) to predict which elderly inpatients will fall: case-control and cohort studies.
British Medical Journal 315: 1049-1053. Available at:
www.bmj.com/cgi/content/full/315/7115/1049
Oliver D et al. (2004) Risk factors and risk assessment tools for falls in hospital inpatients:
a systematic review. Age and Ageing. 33: 122-130
The Patient Safety First Campaign have recently issued a ‘How to’ Guide for reducing
harm from falls. http://www.patientsafetyfirst.nhs.uk/ashx/Asset.ashx?path=/Interventionsupport/FALLSHow-to%20Guide%20v4.pdf
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Prevention Package for Older People
http://www.dh.gov.uk/en/SocialCare/Deliveringadultsocialcare/Olderpeople/Preventionpack
age/index.htm
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/document
s/digitalasset/dh_103152.pdf
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/document
s/digitalasset/dh_103151.pdf
http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/@dh/@en/@pg/document
s/digitalasset/dh_103147.pdf
Royal College of Physicians (2008) National Falls and Bone Health in Older People
accessible via (Accessed 9th November 09).
3.
APPENDICES
Appendix 1 – Falls Prevention in Hospital Flow chart
Appendix 2 – In-Patient Fall Flow Chart
Appendix 3 - Risk Assessment for the Prevention and Management of Falls
Appendix 4 – Falls High Risk Treatment Plan
Appendix 5 – Falls Low Risk Treatment Plan
Appendix 6 – Falls Medium Risk Treatment Plan
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Appendix 1
Falls prevention in hospitals Flow chart
Patient Admitted
ASSESS &
IDENTIFY
RISKS
ASSESS &
IDENTIFY
RISKS
MANAGEMENT
Falls assessment to be completed to identify risk factors
Patient Specific (Intrinsic)
●Cognition & behaviours
●Mobility and transfer skills
●Incontinence
●Medical conditions
●Medication review
●Vision/hearing
●Footwear & clothing
Environmental (Extrinsic)
●Lighting
●Bed height
●Room free of clutter
●Mobility aids
●Call bell
●Route to toilet/commode clear
Is patient able to engage in joint planning of preventative strategies?
NO
those with cognitive
impairment or dementia)
YES
(includes
STRATEGIES
● Increase
Observation.
● Move patient
close to nurses
station.
● Supervise
mobilisation and
toileting.
●Assessment of
behaviours
STRATEGIES
● Medication review, avoid
sedatives, hypnotics.
 Regular toileting plan.
 Orientation to ward.
 Call bell within easy reach.
 Ultra low beds/bed at lowest
height and brakes on.
 Night lights
 Mobility aids check.
 Glasses and hearing aids
within easy reach.
 Use of non-slip footwear
and mats/flooring.
 Area clear of hazards.
 Use of alarm devices.
 Referral to therapists.
 Involve family –
education and care about
the seriousness of falls.
 Provide patient with
information about falls
Complete Treatment Plan
REASSESS
POST FALL
DISCHARGE
Version Number
Reassess risk according to assessment, (‘high’ - daily, ‘medium’ – 4 days, ‘low’ 7 days), or if any changes occur. Review/adjust management plan, and update
documentation.
Patient – See best practice guide, Reassess, implement, document and
communicate to staff post fall assessment and management plan.
Health and Safety - Complete incident form, review environment and manage
risk.
Onward referral to Therapy Teams in your area if risk of falls in community is
identified
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APPENDIX 2
PATIENT FALL FLOW CHART
Patient Fall Flow Chart
Check for signs of physical injury

No significant signs of Injury
 Deformity of limbs
Loss of sensation to limbs
 Pain
 Bleeding
 Head injury
● Return patient to bed/chair using appropriate
moving and handling technique and equipment.
● Record neurological observations if there is a
head injury or UNWITNESSED FALL
● Record baseline observations using early warning
score chart if NO head injury.
● Assess for pain and administer pain relief as
prescribed - Patients with head injury should not
receive systemic analgesia until fully assessed so
that an accurate measure of consciousness and
other neurological signs can be made.
● Repeat Neurological observations after 2 hours. If
stable repeat after 4 hours then daily.
If Glasgow Coma Scale (GCS) is 15 revert to daily
observations unless clinical signs of deterioration.
Re-check for signs of physical injury
 Swelling
 Pain
 Bruising
 Loss of sensation
 Deformity of limbs






Signs of significant injury
Dial 999 for ambulance
Do not move patient
Administer first aid to any
bleeding points
Record neurological
observations
Keep patient comfortable
Keep patient Nil By Mouth
● Repeat Neurological observations:
Half-hourly for 2 hours
Then 1-hourly for 4 hours or until
the ambulance arrives.
If GCS is below 15 neurological
observations should be recorded every
30mins
● Complete SBAR Urgent Transfer
Form
● Consider pain relief, pressure area care and fluid
intake
● Inform practitioner responsible for the patients care
at the next review or earlier if condition indicates.
Further investigations may be requested to determine
cause of fall.
● If fall occurs out of hours inform the responsible
practitioner next working day or contact out of hours
service. MIU can be accessed if required.
● Inform next of kin
● Review and re-assess Patient records, refer to
Patient Falls Management Policy and Slips Trips &
Falls Policy.
● Initiate falls (re)Assessment and treatment plan.
● Complete Incident Form
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


Contact next of kin
Ensure patient records are
completed
Complete Incident Form
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INPATIENT FALLS MANAGEMENT POLICY
APPENDIX 3
SURNAME
NHS No
___/___/____
HOSPITAL
FORENAME
MALE / FEMALE
WARD
ADDRESS
D.O.B
GP/Consultant
RISK ASSESSMENT FOR THE PREVENTION & MANAGEMENT OF FALLS
Date of Admission: _ _ / _ _ / _ _ _ _
Barthel Transfer Score
Date
Patient unable to transfer/immobile
Major help needed (one/two people,
physical aids)
0
Minor Help Needed (verbal or physical)
2
Independent
3
1
Barthel Mobility Score
0
Patient immobile
Independent with the aid of a wheelchair
1
Walks with help from one person
2
Independent
3
Total
Adapted from STRATIFY:
1 Is the patient aged 65 years or over?
Did the patient present at hospital with
2 a fall? Or has the patient fallen on the
ward since admission?
3
Is the patient agitated or confused?
Version Number
Yes =
1
No =
0
Yes
1
No
0
Yes
1
No
0
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=
=
=
=
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INPATIENT FALLS MANAGEMENT POLICY
Is the patient visually impaired to the
4 extent that every day function is
affected?
Has the patient a combined Barthel
5 mobility and transfer score >3
Yes
1
No
0
Yes
1
No
0
=
=
=
=
TOTAL
Signature:
RISK ASSESSMENT
Low Risk
0-1
Date & Time
Medium Risk 2
High Risk
> or = 3
COMPLETE SCREENING PLAN FOR ALL PATIENTS
© Copyright 2009 Quality & Integrated Governance Team, Derbyshire Community Health
Services
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APPENDIX 4
SURNAME
NHS
No
___/___/___
_
HOSPITAL
FORENAME
MALE / FEMALE
ADDRESS
D.O.B
WARD
GP/Consulta
nt
FALLS HIGH RISK TREATMENT PLAN
Date
&Time
Problem
No
Problem / Need
Initials
Stop
Date
…………………………. has been assessed under the DCHS
falls risk assessment and is at HIGH risk of falls.
Date/
Time
Goals Agreed With Patient
Initials
To minimise the risk of falling.
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Policy date
Achieved
Yes (Y) Date
No (N) /Time &
Initial
INPATIENT FALLS MANAGEMENT POLICY
Treatment Plan
Has the person got capacity to consent to this Treatment Plan?
Yes □ No □ If “No” complete Capacity Assessment
Consent obtained? Yes □ No □ If “No” document reason/action ………………………………………
Date
and
Time
Treatment
to be
Performed
By
Treatment Plan
Considering any cognitive impairment will have an impact upon calling
for assistance ensure the nurse call bell is in reach and implement
additional strategies as required to minimise the risk of falling
Considering
any cognitive impairment will have an impact to
orientation around the bed area /ward
Highlight the layout of the ward including toilet areas to patients who
may require to use the toilet more urgently. Implement additional
strategies as required to minimise the risk of falling
Ensure that personal effects (e.g. glasses, hearing aids etc) including
mobility aids are within easy reach and that the environment is not
cluttered.
Is ……………………in the best location on the ward in relation to
visual observation from the staff base
Record postural blood pressure and report any abnormalities to
appropriate clinician.
Assess, plan and document management of night time activity.
Report to appropriate Clinician to review all medication if more than 4
prescribed.
Date requested ………………………………………….
Consider nursing on a high/low bed at its lowest level with crash mat at
the side
Consider 1:1 nursing or request family assistance
Consider use of sensor alarms if available to bed and/or chair
Required yes / no Please circle
Date applied ……………………………………………………..
Check footwear is correctly fitted and if not inform relatives
Date informed ……………………………………
Ensure Manual handling plan is up to date
MDT review Has the level of risk changed ? If no continue ,if yes
complete a new risk assessment and plan
Discharge . Is follow up required Yes / No (please circle)
Document any actions taken
Other actions to be considered
Treatment Plan to be evaluated/reviewed minimum weekly or as changes occur
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INPATIENT FALLS MANAGEMENT POLICY
APPENDIX 5
SURNAME
NHS
No
___/___/___
_
HOSPITAL
FORENAME
MALE / FEMALE
ADDRESS
D.O.B
WARD
GP/Consulta
nt
FALLS LOW RISK TREATMENT PLAN
Date
&Time
Problem
No
Initials
Problem / Need
Stop
Date
…………………………….. has been assessed via the DCHS
falls risk assessment and is at LOW RISK of falls.
Date/
Time
Goals Agreed With Patient
Initials
To minimise the risk of falling.
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Achieved
Yes (Y) Date
No (N) /Time &
Initial
INPATIENT FALLS MANAGEMENT POLICY
Treatment Plan
Has the person got capacity to consent to this Treatment Plan?
Yes □ No □ If “No” complete Capacity Assessment
Consent obtained Yes □ No □ If “No” document reason/action …………………………………….……
Date
and
Time
Treatment
to be
Performed
By
Treatment Plan
Considering any impairment if present, to cognition ensure the
nurse call buzzer is in reach and………………………….can
understand how to use it..
Considering any impairment if present to cognition, ensure
orientation to the ward and its layout
Highlight the toilet areas to patients who may require access
more urgently
Ensure that personal effects (e.g. glasses, hearing aids etc)
including mobility aids are within easy reach and the environment
is not cluttered.
Report to appropriate Clinician to review medication if more that 4
medications prescribed
Date requested………………………………………………………
Check footwear is correctly fitted and if not inform relatives
Date informed (applicable)…………………………………………….
MDT review – Has level of risk changed?
If no continue, if yes complete a new risk assessment and plan.
Ensure Manual Handling plan is up-to-date.
Any other actions to be considered
Treatment Plan to be evaluated/reviewed minimum weekly or as changes occur
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APPENDIX 6
SURNAME
NHS
No
___/___/___
_
HOSPITAL
FORENAME
MALE / FEMALE
ADDRESS
D.O.B
WARD
GP/Consulta
nt
FALLS MEDIUM RISK TREATMENT PLAN
Date
&Time
Problem
No
Initials
Problem / Need
Stop
Date
………………………. has been assessed under the DCHS falls
risk assessment tool and is at MEDIUM risk of falls.
Date/
Time
Goals Agreed With Patient
Initials
To minimise the risk of falling.
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Achieved
Yes (Y)
Date
No
/Time &
(N)
Initial
INPATIENT FALLS MANAGEMENT POLICY
Treatment Plan
Has the person got capacity to consent to this Treatment Plan?
Yes □ No □ If “No” complete Capacity Assessment
Consent obtained? Yes □ No □ If “No” document reason/action ………………………………………
Date
and
Time
Treatment
to be
Performed
By
Treatment Plan
Considering any cognitive impairment will have an impact upon
calling for assistance, ensure the nurse call buzzer is in reach
and implement additional strategies as required to decrease risk
of falling.
Considering any cognitive impairment will have an impact to
orientation around the bed area/ward.
Highlight the layout of the ward including toilet areas to patients
who may require to use the toilet more urgently. Implement
additional strategies as required to decrease risk of falling.
Ensure that personal effects (e.g. glasses, hearing aids etc)
including mobility aids are within easy reach and that the
environment is not cluttered.
Is ………….. …in the best location on the ward in relation to
visual observation from the staff base
Record postural blood pressure and report any abnormalities to
the appropriate clinician.
Assess, plan and document night time activity.
Report to appropriate Clinician to review all medication if more
than 4 prescribed.
Date requested ………………………………………………..
Check footwear is correctly fitted and if not inform relatives
Date informed (if applicable) …………………………………
Ensure Manual Handling Plan is up to date
MDT review – Has the level of risk changed ?
If no continue ,if yes complete a new risk assessment and plan
Discharge – Is follow up required Yes /No (please circle)
Document any follow up actions
Other actions to be considered
Treatment Plan to be evaluated/reviewed minimum weekly or as changes occur
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INPATIENT FALLS MANAGEMENT POLICY
4. AIM
The aim of this Policy is to manage the risk of, and reduce the incidence of, and thereby reducing
the harm from; older people experiencing falls in DCHS Community Hospitals. The Policy
provides a framework with quality standards to:
 identify people who have fallen and or who are at risk of falling again
 assess the level of risk for individuals
 generate, implement and evaluate appropriate treatment plans
 identify the need and scope for and of a specialist falls intervention.
There is an expectation that clinicians will use the framework within everyday practice within
DCHS.
It recognises that falls are a multi-dimensional problem which requires a partnership approach
across the localities and between health, social care and voluntary organisations. DCHS will
deliver a service/pathway which will be based upon evidence-based practice as stated in key
national guidelines (NICE). Our services will use, as part of the framework, validated tools to
support the assessment and treatment process.
5.
BACKGROUND
A patient falling is the most common patient safety incident reported to the National Reporting
and Learning Service (NRLS) from inpatient services. Over 200,000 falls were reported to
the Reporting and Learning System (RLS) in the 12 months from September 2005 to August
2006, with reports of falls coming from 98 per cent of organisations that provide inpatient
services.
Historically the National Service Framework, gave organisations key guidance in the
identification and treatment for patients who have fallen.
NICE guideline CG21 “Falls: the assessment and prevention of falls in older people” was issued
in 2004 to provide guidance on key areas of risk, assessment, interventions, participation and
education for the health care community.
The Department of Health (DH) issued the Prevention Package for Older People which builds on
the National Service Framework and NICE guidance. The Falls and Fractures, effective
interventions in health and social care package outlines four key objectives shown in Table 1.0
(July 2009).
5.1
TABLE - OBJECTIVES
See below
Table 1.0
Objectives - Effective Interventions in Health and Social Care for Falls and Fractures
1.
Improve patient outcomes and improve efficiency of care after hip fractures through
compliance with core standards.
2.
Respond to a first fracture and prevent the second – through fracture liaison
services in acute and primary care settings.
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3.
Early intervention to restore independence – through falls care pathways, linking
acute and urgent care services to secondary prevention of further falls and injuries
4.
Prevent frailty, promote bone health and reduce accidents – through encouraging
physical activity and healthy lifestyle, and reducing unnecessary environmental
hazards.
In order for DCHS to meet the above objective and NICE guideline, the Falls framework and
quality standards will be implemented.
6.
AREA FOR IMPLEMENTATION
All DCHS Community Hospitals.
7.
ORGANISATIONAL ACCOUNTABILITY/RESPONSIBILITIES I.E. CEO,
DIRECTORS, MANAGERS, STAFF
This section to set out who holds organisational accountability and responsibility for the policy.
 The Chief Executive holds overall accountability and is responsible for assuring that there are
effective systems in place to implement the guidance.
 The Director of Service Delivery is the lead operational officer for Derbyshire Community
Health Services and is accountable to the Managing Director.
 The Director of Nursing and Quality is accountable for the quality and delivery of care.
 Operational Managers have responsibility for managing staff groups, risk management, clinical
incidents, and competency practice issues once identified. Records of attendance on training
will be kept by the Trust. Patient records will be audited to monitor compliance with policy.
Staff competency will be evaluated during PDR process.
 Professionally Registered Staff. All staff are accountable for their professional practice and
hold individual responsibility to maintain their knowledge and skills in relation to falls
management. It is their responsibility to identify training needs and plan to meet learning
objectives identified in their PDR.
The policy sponsor is David Muir, Chair of Falls Implementation Group, Pathways & Clinical
Outcome Manager and is responsible for ensuring that:
-
The Policy is developed in line with the DCHS Policy Development Framework;
The Policy is disseminated to its target audience;
Appropriate training is given in the use of the Policy;
The Policy’s implementation is monitored and reviewed on a regular basis.
8.
INTENDED USERS
All clinical staff working for DCHS in an In-Patient setting.
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9.
DEFINITION
Fall:
An event which results in a person coming to rest at a lower
level.
Explained Fall:
We know and understand the reasons that have contributed
to falls.
Intrinsic:
Medical, psychological or physiological reasons for falls.
Extrinsic:
Environmental reasons for falls.
Unexplained Fall:
We do not understand the reasons that have contributed to
falls history. To presume these are more likely to have
medical factors influencing i.e. history of falls
Multi-professional:
Multidisciplinary approach to falls prevention involving
medical, nursing and therapy assessments.
10.
INDICATIONS FOR USE
All patients admitted to DCHS Community Hospitals.
11.
CONTRA-INDICATIONS
None.
12.
EQUALITY IMPACT STATEMENT
We welcome feedback on this policy and the way it operates. We are interested to know of any
possible or actual adverse impact that this policy may have on any groups in respect of gender or
marital status, race, disability, sexual orientation, religion or belief, age, deprivation or other
characteristics.
This Policy has been screened to determine equality relevance for the following equality groups:
Race, Gender, Disability, Age, Sexual Orientation, Religion/Belief, Transgender/ Transsexual.
The Policy is considered to have little or no equality relevance.
The person(s) responsible for equality impact assessment for this policy is:
Edwina Layton. Tel: 01246 515151
13.
MONITORING AND PERFORMANCE MANAGEMENT OF THE POLICY
To measure compliance to the Policy an annual audit will be developed and completed.
This audit will be both of process and record keeping, but also of the quality and impact
Of risk assessments and action plans
The findings of the audits and action plans will be reported and monitored by the Falls
Implementation Group, (FIG). Exceptions will be reported by FIG to the Safety Committee
Version Number
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Policy date
INPATIENT FALLS MANAGEMENT POLICY
and to the Service Delivery Directorate’s Governance Group.
The falls implementation group will define, develop and implement an implementation strategy
across the county.
Monitoring of the Guideline will take place via Falls Implementation Group.
 Audit of number of clinical incidents arising from falls.
 Analysis of data demonstrating uptake of falls training.
 Complaints with regard to receiving falls service.
Review of Guidelines initially after two years or earlier if new national guidance is released
14.
SUPPORT AND ADDITIONAL CONTACTS
Name
David Muir
Jennifer
Harrison
Joanna Sills
Title
Chair of Falls
Implementation Group
Matron and In-patient Lead
Integrated Manager
Base
Babington
Hospital
Ilkeston Comm
Hospital
St Oswald’s
Hospital
Walton Hospital
Adelle
Clements
Patient Safety Manager
Peter Sloan
Older Peoples Mental Health Newholme
Liaison and Practice
Development nurse
Occupational
Ash Green
Therapist/Occupational
Therapy Team Leader –
Learning Disabilities
General Manager
Walton Hospital
Nancy Abbotts
Edwina Layton
Version Number
Page 20 of 21
Contact Number
Telephone:
01773 525074
0115 9305522
Telephone:
01335 340806
Telephone:
01246 515814,
Mobile:
07824 624452
Telephone:
01629 817945
Telephone:
01629 532317
Mobile:
07881850226
Policy date
INPATIENT FALLS MANAGEMENT POLICY
EQUALITY & DIVERSITY IMPACT ASSESSMENT :
Race
Which of the following diversity
profiles could suffer detriment as a
result of this policy / procedure
/process?
Religion/Belief
What is the purpose of the policy under assessment?
What is the background to the policy? (e.g. in response to
a statutory requirement, development of good practice,
organisational review etc..)
Who is intended to benefit from the proposed policy?
Is there any potential for impact on non-beneficiaries?
Is there up to date data on the groups/individuals on
whom there may be impact?
Have there been changes to the equalities profile of the
above groups/individuals since the collection of the data?
Does the policy influence in a positive way relations
between different groups of people?
LEVEL I SCREENING
Gender
Disability
Age
Sexual
Orientation
Transgender/
ALL GROUPS
Transsexual
The purpose of the policy is to screen, risk assess and treat patients who are
at risk of falls living in the community or hospital.
The back ground of the policy is to develop benchmark good practice
against national guidelines.
All patients who is at risk of or fears falling.
The policy is for patients that are identified as at risk of falls or who fall whilst
under the care of DCHS there is no impact on non-beneficiaries.
This policy will impact upon patients being treated by DCHS and the
implementation of a screening, risk assessment and treatment process to
support the identification of those at risk of falls. Data on patients who have
fallen whilst under the care of DCHS can be obtained from Datix.
No
It aims to be inclusive for those who are at risk of falls. It forms part of the
falls pathway from identifying to specialist assessment / treatment.
It gives the opportunity for screening, risk assessment and specialist
Does it promote equality of opportunity?
assessment for patients within DCHS relating to falls.
Does the function either eliminate or contribute to the
Although policy is biased towards older people, the policy recognises there
elimination of unlawful; discrimination across all equalities are other patient groups in the community who may be at risk of falls due to
themes?
acute or long term conditions.
The policy also links closely with the bed rails and in-patient policies.
Are there any concerns expressed about the policy having No
the potential for adverse impact on any group/s of people?
Assessment Outcomes High
No further action Required level 2 assessment by Dec 2012
Level 1 assessment – signing off date: Dec 2010
Version Number
Page 21 of 21
Assessment carried out by: Edwina Layton
Policy date