Falls Prevention and Documentation in Care Homes

Falls affect approximately 30% of people over 65 each year, and the risk is even higher in care home settings. While not all falls can be prevented, comprehensive documentation helps identify risk factors, track incidents, and implement effective prevention strategies.

Falls Risk Assessment

Every resident should have a falls risk assessment on admission and regular reviews. Document these key risk factors:

Using the Falls Risk Assessment Tool

Many care homes use standardised tools like STRATIFY or the Downton Fall Risk Index. Whichever tool you use, document:

• Date and time of assessment
• Risk score and what it means
• Specific risk factors identified
• Interventions put in place
• Review date (typically monthly or after any fall)

Prevention Strategies Documentation

For each identified risk factor, document specific interventions in the care plan:

Post-Fall Documentation Protocol

When a fall occurs, thorough documentation is essential for resident safety, learning, and legal protection. Follow this sequence:

Immediate Response (Document in real-time)

1. Time discovered: Exact time the fall was found or witnessed
2. Location: Precise location (room number, bathroom, corridor)
3. Position found: How was the resident lying/sitting?
4. Witnessed or unwitnessed: If witnessed, what happened?
5. Initial assessment: Consciousness, pain, visible injuries
6. First aid given: Any immediate treatment provided

Physical Assessment Documentation

Complete a head-to-toe assessment and document:

• Neurological observations (if head injury possible)
• Skin integrity check for wounds, bruising, swelling
• Pain assessment (location, severity, type)
• Range of motion if limb injury suspected
• Vital signs including lying/standing blood pressure

Investigation Documentation

After ensuring the resident is safe, document the circumstances:

• What was the resident trying to do?
• Were they wearing appropriate footwear?
• Was their walking aid within reach?
• Environmental factors (wet floor, obstacles, lighting)
• Time since last check
• Staffing levels at the time
• Any equipment failure

The Falls Incident Form

A comprehensive falls incident form should capture:

Post-Fall Review Process

Within 24-48 hours of any fall, conduct and document a formal review:

1. Root cause analysis: What factors contributed to this fall?
2. Risk assessment review: Does the falls risk score need updating?
3. Care plan review: What changes are needed to prevent recurrence?
4. Equipment review: Is current equipment appropriate?
5. Referrals needed: GP, physiotherapy, occupational therapy, optician?
6. Family discussion: What was communicated and agreed?

Using Falls Data for Prevention

Individual incidents tell one story; patterns tell another. Regularly analyse your falls data to identify:

CQC Expectations

CQC inspectors will examine your falls management. They expect to see:

• Comprehensive risk assessments for all residents
• Individualised prevention strategies in care plans
• Thorough post-fall documentation and investigation
• Evidence of learning from falls analysis
• Appropriate referrals and follow-up
• Staff training in falls prevention
• Governance processes for falls monitoring

Notification Requirements

Certain falls must be reported externally:

• CQC notification: Falls resulting in serious injury (fracture, head injury requiring hospital treatment)
• Safeguarding referral: If the fall resulted from neglect or abuse
• RIDDOR: If the fall was caused by a workplace hazard and results in specified injury
• Coroner: If the fall contributes to a death

Conclusion

Falls prevention isn't about eliminating all risk—that would mean restricting residents' freedom and independence. It's about understanding each person's individual risk factors and putting proportionate measures in place to reduce harm while maintaining quality of life.

Good documentation is the foundation of effective falls management. It helps you understand patterns, demonstrate learning, and show families and regulators that you're doing everything reasonable to keep residents safe.