Falls Prevention and Post-Falls Review Audit - Care Homes

Evidence to check

• • Falls policy is current, reviewed and accessible to staff
• • Policy covers prevention, immediate response, observations, escalation, reporting and learning
• • Staff can explain what to do after a fall, including unwitnessed falls and suspected head injury
• • Practice observed or sampled matches the written policy

Evidence to check

• • Falls risk assessment completed on admission
• • Assessment reviewed after falls, near misses, hospital discharge, medication changes or deterioration
• • Review dates are current and clearly recorded
• • Changes from reviews are reflected in the care plan

Evidence to check

• • Care plan identifies history of falls, mobility, cognition, eyesight, continence, footwear, medication and frailty risks
• • Risk factors are linked to specific interventions
• • Staff can explain the resident's main falls risks
• • Daily notes show staff following the falls prevention plan

Evidence to check

• • Mobility aids are clean, labelled where needed and in good repair
• • Aids are within reach when residents need them
• • Staff know how each resident should mobilise
• • Faulty or unsuitable equipment is reported, removed from use and replaced promptly

Evidence to check

• • Residents have suitable footwear or risk is recorded if they choose otherwise
• • Long clothing, loose slippers or unsafe footwear risks are discussed sensitively
• • Flooring, rugs and mats are checked for trip hazards
• • Resident choice and positive risk-taking are considered and documented

Evidence to check

• • Walkaround checks show areas are free from avoidable clutter and trip hazards
• • Lighting is adequate, including at night
• • Furniture layout supports safe movement
• • Hazards are reported and resolved promptly

Evidence to check

• • Call bells are within reach for residents who use them
• • Grab rails and handrails are secure and suitable
• • Residents know how to use call bells or alternative alert systems
• • Checks are made that safety aids remain accessible after care tasks

Evidence to check

• • Daily notes record changes in mobility, balance, dizziness or strength
• • Concerns are escalated to senior staff, GP, nurse, physiotherapist or falls team where needed
• • Care plan is updated when changes are identified
• • Staff handovers include new or increasing falls risks

Evidence to check

• • Referral records to physiotherapy, OT or falls service
• • Professional advice is added to the care plan
• • Equipment or exercise recommendations are followed
• • Delays in professional input are chased where risk remains

Evidence to check

• • Medication reviews completed after repeated falls or significant falls
• • GP, pharmacist or prescriber input recorded
• • Sedatives, hypnotics, antipsychotics, diuretics, antihypertensives and pain medicines considered where relevant
• • Medication changes and monitoring actions are reflected in the care plan

Evidence to check

• • Nutrition and hydration care plans are current
• • Food and fluid intake monitored where required
• • Concerns about dehydration, poor intake or weight loss are escalated
• • Falls reviews consider whether nutrition or hydration contributed

Evidence to check

• • Post-fall assessment record completed after each fall
• • Vital signs, neurological observations or head injury monitoring completed where indicated
• • Pain, mobility, injury and skin condition are checked
• • GP, NHS 111, ambulance or emergency services contacted where required

Evidence to check

• • Incident reports and notification records
• • Relatives or representatives informed according to care plan and policy
• • Safeguarding considered for unexplained, repeated, serious or potentially avoidable falls
• • CQC notification considered where injury or regulatory threshold applies

Evidence to check

• • Falls incident forms include time, location, activity, witnesses and injury details
• • Environmental factors such as lighting, footwear, clutter, wet floors or equipment are recorded
• • Witness accounts are included where available
• • Immediate actions and escalation are clearly documented

Evidence to check

• • Team meeting minutes, handovers or safety briefings include falls learning
• • Care plans or risk assessments updated after learning
• • Environmental changes, equipment changes or staffing actions are completed
• • Staff can describe recent falls learning and what changed

Evidence to check

• • Falls analysis reports completed at least monthly or in line with policy
• • Trends identify hotspots, repeat fallers, night-time falls, toileting-related falls or staffing patterns
• • Actions are agreed in response to trends
• • Trend data is reviewed by managers and shared with staff

Evidence to check

• • Repeat faller tracker or falls register
• • Multi-fall reviews completed after repeated incidents
• • Care plan, risk assessment, medication and equipment reviewed
• • Professional referrals made where repeated falls continue

Evidence to check

• • Interventions such as sensor mats, low beds, hip protectors, increased checks or equipment are individually risk assessed
• • Consent, capacity and dignity are considered
• • Interventions are reviewed to check whether they reduce risk
• • Restrictive or intrusive measures are justified, proportionate and reviewed

Evidence to check

• • Training records for moving and handling, falls prevention and post-falls response
• • Staff can explain what to do after a witnessed and unwitnessed fall
• • Competency checks or observations confirm safe mobility assistance
• • Training is refreshed after incidents or audit findings

Evidence to check

• • Care reviews include discussion of falls risk and resident wishes
• • Resident or representative views are recorded
• • Risks are explained in a way the resident can understand
• • Care planning balances safety with independence, dignity and choice

Evidence to check

• • Post-fall follow-up records
• • Injury, pain, mobility and wellbeing are reviewed after the fall
• • Professional advice is followed and recorded
• • Family or representative updates are documented where appropriate

Evidence to check

• • Governance reports include falls data and trends
• • Quality improvement plan includes falls actions where needed
• • Senior leaders review serious or repeated falls
• • Actions are tracked and reviewed for impact

Evidence to check

• • Falls review records assess whether current interventions worked
• • Interventions are changed where they are ineffective
• • Resident feedback and staff observations are considered
• • Reviews check for unintended consequences such as reduced independence or distress

Evidence to check

• • Injury records classify severity and treatment required
• • Safeguarding considered for serious, unexplained, delayed-response or repeated injuries
• • Clinical escalation is documented
• • Learning from injury reviews is reflected in care plans and practice

Evidence to check

• • Debrief records after serious or significant falls
• • Staff emotional support considered where falls were traumatic
• • Debrief identifies what went well and what needs improvement
• • Learning is shared and followed up

Evidence to check

• • Falls reviews consider whether the resident was going to or from the toilet
• • Continence care plans and night checks are reviewed after relevant falls
• • Call bell access, lighting, footwear and mobility aids are checked for night-time use
• • Changes are made where toileting-related falls are identified

Evidence to check

• • Falls audit samples incident records, care plans, observations and staff knowledge
• • Audit checks whether actions were completed and effective
• • Resident and family experience is considered where appropriate
• • Audit findings lead to practical improvements