FALLS PROJECT 2012 Falls Auditing Ø Falls

FALLS PROJECT 2012

Falls Auditing Ø Falls audits in the care homes had traditionally focused upon the number of falls per month – was a paper exercise with no visible positive outcomes Ø Merely looking at the number of falls does not enable you to establish any trend or cause behind the number Ø Falls audits in their old format were time consuming, duplicated information already held and were of no value to the staff or residents Ø Staff understanding and ownership of falls management was limited with a perception that ‘falls happen’ and without preventing residents from mobilizing they would continue to fall

Falls Plotting Initiative Ø NHS Institute for Innovation & Improvement commenced test site work at Robinson House in May 2012 for a Well Being in Care Homes project Ø The Institute visited towards the end of the project to discuss data measurement Ø Looking at systems we audit, we decided to focus upon falls – how we collect the information following a fall, how it is analysed, what we do with the analysis Ø Embarked upon falls plotting which immediately provided evidence of trends and causal factors – Focus on time & location of fall Ø Although it is still important to be aware of the number of falls, looking at days between falls, time & location enabled staff to establish a trend Ø Statistically, a run of 5 – 7 points on a line chart will suggest that something is not happening at random – there is an underlying cause. 1 or 2 points can be random events occurring and there may be no cause or trend behind them

NHS Institute for Innovation & Improvement - Data

NHS Institute for Innovation & Improvement - Data

Plotting the Location

Plotting the Time

Number of falls – in context

Results! üStaff ‘on the floor’ have made the changes – where they allocate their time, when breaks are taken, better understanding of ‘at risk’ residents üImmediate reduction of falls in a 4 week period of 60% in one home üHas now been introduced to all the homes as the falls audit process – reduction of 40% - 60% in all homes üFalls audit using plotting and mapping is quick, easy to understand makes a real difference – no longer just a paper exercise üAmount of documentation and subsequent duplication of information has been reduced significantly üCQC & HSC very impressed with this approach to falls management – demonstrates a proactive rather than reactive culture üPlotting of SGA incidents resident to resident altercations, to establish trends

What have we learnt? The key to success has been involving the staff as they are the ones who will make the difference on the floor. Staff really understand the plotting and the concept of days between falls. The information is visual, has an immediate impact and does not have to be computer generated. Looking at a number of different factors enables you to gather a true picture of what the actual issues are – a number on its own merely provides a snapshot that can be misleading – you may put the wrong corrective or preventative measure in place if you do not have the full information. Falls happen for a reason and a pattern can almost always be established for those residents who repeatedly fall. The patterns and trends you uncover can be surprising! Auditing in this way adds real value and makes a positive difference for residents

Sandra Payne Head of Clinical Excellence Brunelcare email – sandra. payne@brunelcare. org. uk Mob – 0778 6706227