Edward Mallaby

R

Roseberry Care

Mr D Winter

Deputy Chief Coroner of England and Wales and Her Majesty's Senior Coroner for the City of
Sunderland

Civic Centre

Burdon Road

Room 2.108 Office of HM Coroner

Sunderland

SR2 7DN

Dear Mr Winter 12!h January 2021

Further to the Regulation 28 Report to Prevent Future Deaths received on 10 December 2020 in
respect of the late Mr Edward Mallaby; as per the terms of that report | wish to confirm that actions
taken to reduce the risk of future deaths at Alexandra View Care Home and across the Roseberry
Care Centres portfolio of homes.

| wish to reassure you that action has been taken to improve our policies and tighten our procedures
considering the accident and the outcome of the inquest.

We have discussed the accident involving Mr Mallaby at our Group Care and Clinical Governance
meetings and have agreed a number of changes to policy.

Please find enclosed updated policies in respect of:

e Residents Belongings
e Admission of a Resident
e Management and Prevention of Falls

These polices have been issued to the homes throughout the Group with ‘read and sign’ sheets to
ensure and evidence that all staff have read the changes to policy. Specifically, in Alexandra View
these updated policies have been introduced in small group supervision sessions so staff have the
opportunity to discuss their understanding and raise any questions. This process, at Alexandra View,
was completed on 31s December 2020.

ROSEBERRY CARE CENTRES GB LTD

1st Floor, Valley View Care Centre, Penshaw,
Houghton-Le-Spring, Tyne & Wear, DH4 7ER

+ 0191 549 0506
pec
Company Secretary} # 0191 385 4001
Company Registration Number: GB 6281674

headoffice @roseberrycarecentres.co.uk
www.roseberrycarecentres.co.uk

The policy updates cover the areas as highlighted during the inquest and as detailed in the report
received 10 December 2020:

e Management of residents property, which may be hazardous

e Sensor mat monitoring

e Frequency of observations, including whether bedroom doors should be open or closed

In addition, | have introduced an Observation and Monitoring form {also enclosed) to be used in
accordance with the updated Management and Prevention of Falls policy and updated the Falls Risk
Assessment to reference this new record (attached). At the time of Mr Mallaby'’s accident, sensor
mats were checked at each shift changeover and recorded on the handover by the person in
charge. The introduction of this form will ensure sensor equipment is checked for its position and that
it is in working order throughout the shift and a minimum of hourly. This amendment to policy and
additional checking is being monitored daily at Alexandra View by on site senior management.

The staff at Alexandra View have also repeated their Prevention and Management of Falls training to
refresh their knowledge; all staff successfully completed this by 7» January 2021.

Should you require any further information please do not hesitate to contact me.

Yours sincerely

Chief Executive
Roseberry Care Centres

Enc.

R

Roseberry Care

Admission of a Resident
Date: 24 April 2012

Policy team: Operations

Review Date | Reviewed Sections
July 2020
17.12.20

Review
Reviewed 2.1, 3.1.4, 3.2.3
Added 3.3.12, 3.2.13

Next review date 17.12.21

Reference to Procedures and other Polices:

Service Users Belongings

Policy CA-PR-08

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

1.0 POLICY

1.1

2.0

2.1

2.2

2.3

24

3.0

3.1

Each new Resident will be warmly welcomed into the Care Centre and all appropriate
documentation will be completed in order to provide effective person-centred care.

RESPONSIBILITIES

Home Manager is responsible for implementing this policy to ensure that all new
Residents are made welcome and that their needs and preferences are properly
identified, any risks are identified, and they made known to relevant staff members.

Person in Charge is responsible, in the absence of the Home Manager, for the
implementation of this policy.

Named Nurse/Key Worker is responsible for the introduction into the Care Centre of
each new Resident allocated to their care, and for developing person centred care
plans in collaboration with the Residents and / or their representative.

The Administrator is responsible for maintaining the register of new Residents coming
into the Care Centre.

PROCEDURE

Preparation

3.1.1 Subsequent to the successful pre-admission assessment of a prospective new Resident,

3.1.2

3.1.3
3.1.4

preparations are made in anticipation of the new Resident's arrival in the Care Centre.

The Home Manager will inform the appropriate staff members in the Daily Safety
Huddle in the days prior to and on the day of admission and ensure that the Resident's
accommodation is properly prepared.

Where possible the new Resident is given a choice of room.
Preparation of the Resident's room includes the following:

« The Resident's name is typed; using their preferred name / title, and secured to
the bedroom door

* The bedroom and, where applicable, en-suite are clean and fresh and have been
redecorated as necessary.

* The Resident's bed is freshly made up; clean towels and toilet tissue are
available in the en-suite where applicable.

* Equipment required based on the pre-admission information will be available
pending assessment of need and mental capacity / Best Interest e.g., bedrails,
sensor mat, pressure mattress

* The bedroom lay out should be discussed with the Resident & Relative to reduce
the risk of falls e.g., access to ensuite, orientation for those who suffer from
Dementia and based on the moving & assisting assessment, to allow for correct
moving & handling needs to be carried out should a slide sheet or hoist be
assessed as required for safe practices.

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

3.2

3.2.1

3.2.2

3.2.3

3.2.4

3.2.5

3.3
3.3.1

3.3.2
3.3.3
3.3.4

Prior to the arrival of the new Resident, the Home Manager will delegate a Named
Nurse/Key Worker and a Named Carer. Wherever possible, both of these staff
members will be on duty to assist the new Resident to settle into the new
surroundings of the Care Centre.

New Resident Reception (this procedure may differ in light of Coronavirus risk
management assessments which may be in place)

On arrival at the Care Centre the new Resident and Relatives are made welcome
by the Home Manager personally whenever this is possible. The person in charge
to assess whether light refreshments, in accordance with the known care needs,
may be served in order to help them feel welcome and at ease.

The Home Manager ensures that the new Resident and Relatives are provided with
the necessary information regarding life in the care home in the form of a Service
User Guide.

The Person in charge will decide if it is appropriate for the Resident to be given a
tour of the Care Centre depending on the individual or the home’s current status of
any infection — isolation may be in place. Only where possible, the Resident &
Relative, is accompanied to be introduced to the Named Nurse/Key Worker and
Named Carers. Similarly, introductions are made to other staff members and to
fellow Residents only where possible and assessed safe to do so.

Where it has not been possible for the new Resident to be introduced to the Named
Nurse/Team Leader or the Named Carer on arrival at the Care Centre, appropriate
introductions should take place normally within 24 hours of Admission.

A Resident, once settled into the care home, may wish to choose their own named
nurse and / or key worker. Changes will be recorded in the Residents care notes as
applicable

New Resident admission

The Care Centre Manager will ensure that all relevant information pertaining to the
Resident is made available to the Care Centre Administrator to enable the
preparation and completion of the necessary financial documentation on the day of
admission.

The Care Centre Administrator will complete the Register of Residents.
The new Resident Care File is prepared by the admitting staff member.

Referencing the information in the pre-admission assessment and any other
updated information, i.e., discharge letter if from transferred from hospital, social
worker assessment, trusted assessors’ assessment, the admitting staff member will
plan appropriate person-centred care, including appropriate information relating to
the Resident's social and medical history, including evidence of Power of Attorney.
Any documentation to evidence ¢.g., DNAR to be updated with the current details
i.e., change of address asap. The development of the care file must be completed
with the Resident and / or name Next of Kin / Lasting Power of Attorney for Health
& Welfare

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

3.3.5 A 72hrs care plan will be formulated which will include immediate care needs. The
following risk assessments must be completed on admission —

* Moving and Handling
* Choking

* MUST

* Waterlow

* Falls

* Dependency

Review of need of a Deprivation of Liberty safeguarding & Best Interests
Assessment

3.3.6 The following observations will be recorded within 12 hours:

e Pulse, weight, height, respirations, temperature, B.P. and Blood Sugar (BM) for
nursing Residents.

3.3.7 A Personal Emergency Evacuation Plan (PEEPs) will be recorded for both day &
night-time requirements. 1 copy for the care file and 1 copy to be placed in the
emergency evacuation bag

3.3.8 A body map will be completed and recorded as soon after admission as possible but
within a maximum of 6 hours. Clinical photograph should be considered and
conducted in accordance with the Clinical Photography policy as necessary

3.3.9 The admissions/readmission protocol will be followed in that the Care Centre
Manager will check the file is complete within 72 hours of admission.

3.3.10 |The Named Nurse/Key Worker will formulate person centred care plans in
collaboration with the Residents and/or representative LPA health & welfare as per
policy Person Centred Care (CA-PR-01) within 7 days of admission.

3.3.11. The Care Centre Manager will audit the care file 7 days after admission as per
Quality Assurance Audit and Meeting Schedule.

3.3.12 It is recognised by Roseberry Care Centres that Residents may wish to bring items
from home into the Care Home. We would always try to accommodate these items but on
occasion it may be necessary to prevent these items being brought into the Care Home or the
timing of their acceptance into the Care Home may need to be negotiated. Such occasions
may include:

a) Electrical items need to be either visually checked for their safety if items are new
or Portable Appliance Tested if used; therefore, these items will not be accepted into the Care
Home out of business hours as the personnel responsible for these checks does not work
outside of office hours

b) Items which may present as a falls / trip hazard, for example rugs / mats or large
items which may restrict the usable floor space in a bedroom.

3.3.13 The Person in Charge on the day of admission is responsible for conducting a risk
assessment of the items brought into the care home. This should include an assessment of

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

furniture and electrical items; taking into consideration the size of items of furniture and
television sets which may cause a hazardous environment in which to deliver care. For
example, a large sideboard may restrict the turning circle of a hoist needed for moving &
handling, or a large TV may balance unsafely on a standard chest of drawers. Further to this
risk assessment, which must be recorded in the Residents care plan, and in conjunction with
the Residents where able, relatives may be asked to remove items from the Care Home.

3.4 Medication

3.4.1

3.4.2

3.4.3
3.4.4

3.5
3.5.1

3.5.3

3.6
3.6.1

3.6.2

3.6.3

Medicines brought into the Care Centre will be checked and recorded by the
admitting staff member on a MAR chart as per the Medication Management Policy
(CA-PR-64).

In the first instance it may be necessary for the admitting staff member to transcribe
details of the Resident's current medication on to the Medicines Administration
Record (MAR chart) until printed MARs are received from the Pharmacist. Great
care should be exercised to ensure accuracy. The details must be checked and
signed by a second staff member, suitably trained and competent to do so.

Stock balances must be recorded of all medicines received into the care home.

Medicines received, including the prescription, must be cross referenced with any
discharge documentation to ensure any changes to prescribed medicines are
recorded

New Resident's General Practitioner

If the Resident is not currently on the list of a local General Practitioner, the local
protocol is adhered to and registration forms are completed within 24 hours.

If the new Resident is registered with a local General Practitioner, he/she will be
informed of the Resident's admission to the Care Centre within 24 hours.

In the event of an emergency admission and the Resident is not Registered with a
local GP, then Staff are to refer to 111 should advice or treatment be required

Resident’s belongings

Using the record of Residents belongings form the admitting staff member records
details of the belongings brought into the Care Centre by the Resident. The form is
completed carefully ensuring that items of potential value are properly described.
(i.e., yellow metal not gold ring). Photographs of jewellery, ornaments etc. should
be taken so that identification can be made if lost or misplaced.

Where possible the Resident and/or relative will sign the personal belonging sheets.
If this is not possible then a second staff member will sign the personal belonging
sheet.

The Residents’ belongings form clearly states the terms and conditions under which
Residents’ personal property is accepted into the Care Centre in order to indemnify
the Care Centre as far as is practical. This information is also available in the
Service User Guide.

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

3.6.4

3.6.5

3.6.6

3.6.7

3.6.8

3.6.9

For items of value the staff member will advise the Home Manager who will then
advise the Resident/Representative of the limitations of the Care Centre’s insurance
policies, and of the possible need to arrange insurance for the items separately.

The Company reserves the right to refuse to accept the following:

+ Items felt to be of significant value.
* Items that could present a hazard to Health and Safety, e.g., electrical
equipment, and furnishings.

The Resident/Representative will be advised that all clothing must be labelled
discreetly to facilitate subsequent traceability through the laundry process.

All portable electrical items (TVs, razors, hair dryers etc.) will be recorded in the
Care Centres Equipment Maintenance System and, unless new with evidence of
purchase (receipt), will not be used until checked visibly for electrical safety;
thereafter all electrical items will be subject to annual Portable Appliance Testing.

A locked drawer will be made available in the Resident's room for the storage of
valuables and medicines (if self-medicating See CA-PR-65). Duplicate keys are
held by the Care Centre Manager in the event of loss. Additionally, there is a safe
available under the direct responsibility of the Care Centre Manager for the storage
of valuables until such time as safekeeping can be transferred to the safe care of
the Representative at an alternate location.

Both the Resident and Representatives are informed that when new items are
brought into the Care Centre or items previously recorded are removed from the
Care Centre a staff member must be informed and the details recorded on the
Record of Resident's Belongings form.

CA-PR-08 Admission of a resident V4 reviewed Dec 2020

Falls Risk Assessment

Initial Assessment Completed by:

Date:

Mental Status Alert & Orientated or unconscious

2 Disorientated at all times
4 Confused at times
B History of Falls 0 No history of falls
2 1 or more falls in past 12 months
4 1 or more falls in past 3 months
Cc Mobility and/or 0 Mobile & Continent
Elimination 2 Limited or assisted mobility and assisted with
Status toileting
4 Mobile and continence difficulties
D Vision 0 Adequate — with or without glasses
2 Poor — with or without glasses
4 Registered Blind
E Walking & 0 No problems with walking or balance OR

Immobile
Bal
atanies 1 Balance problem whilst standing, walking or
sittin

Co-ordination problems
Jerking or unstable
Shuffles

Uses Zimmer frame or similar walking device

1
1
1
1
- F Dizziness 4 Complains of dizziness when sitting up or
standing up

Respond below based on the following types of medications: Antihypertensives; (Blood
Pressure) Antiseizure; (Epilepsy) Benzodiazepines; Laxatives; Diuretics; Hypoglycaemics;
(Diabetic) Opioids; (Strong Pain Killers) Psychotropics; Sedatives

G Medieaiions None of these medications taken

Takes 1 or 2 of these type of medications

Takes 3 or 4 of these type of medications |

Respond below based on the following predisposing conditions: Hypotension, (Low blood
pressure) Stroke, Dizziness/Vertigo, Diabetes, Parkinson’s Disease, Dementia with Lewy

Bodies, Loss of Limb(s), Seizures, Arthritis, Osteoporosis, Fractures, Fainting
H_ | Iiness/Disease
making falls more 0 None present
likely

2 1 or 2 present

4 | 3 or more present

Section

i

Total a i

Signature

yee nyeye]e]
Pa =

A score of 10 or above represents HIGH RISK

All Residents scoring 10 or above should have a specific care plan and have their
well-being monitored using the Observation and Monitoring form

R

Roseberr

y Care

SERVICE USERS BELONGINGS
POLICY

Date: 24 April 2012

Policy team: Administration

Approved by:

(MD

Review Date Reviewed Sections
| 02.04.13 4.0, 4.1 added
02.04.14 Review
05.11.15 3.1.4, 3.1.5, 3.1.6 added 3.1.7- amended
| 05.11.17 Review
05.11.19 Reviewed 3.1.1 amended
05.11.20 Reviewed 3.1.3, 3.1.5 amended
17.11.20 Reviewed 1.1, 2.1, 2.2, 2.3, 3.1.2, 3.1.3,
3.1.4, 3.1.5, 3.2.1
Added 4.0

Next review date November 2021

Reference to Procedures and other Polices:
Admission of a Resident CA-PR-08

1.0
11
2.0
2.1
2.2

2.3

3.0
3.1
3.1.1

3.1.5

3.1.6

3.2
3.2.1

POLICY

It is Roseberry Care Centres policy to ensure that all belongings brought to
the homes are documented, easily identifiable, risk assessed for their safety
and protected from harm / loss.

RESPONSIBILITIES

Home Manager is responsible for ensuring that all belongings brought to the
home are documented, easily identifiable, and risk assessed for their safety
and protected from harm / loss.

Person in Charge has the responsibility to ensure that all belongings brought
to the home are documented, easily identifiable, and risk assessed for their
safety and protected from harm / loss.

The administrator is responsible for ensuring that all belongings of value
brought to the home are documented, easily identifiable and protected from
harm / loss

PROCEDURE

General

Ensure that all items brought to the home at any time are marked with the
owner's name and room number, this is the responsibility of the next of kin.

On the noticeboards in the home, always keep a reminder to relatives and
friends to pass any additional items brought into the home after the day of
admission, to the staff for tagging and recording in the belongings log.

Any valuables be passed to the administration department for logging in the
safe-keeping log. Photographs are to be taken of any item of value on
admission into the home and held with the safe keeping log for identification
purposes.

Residents should always be advised and encouraged to make their own
arrangements for the safekeeping of valuables and ensure valuables are
insured. The resident’s family / nominated individual should be encouraged to
look after the valuables where the resident is unable to make their own
arrangements.

Where agreed by the Home Manager, the care home will hold items of value
in the safe until the resident leaves or requests return of the items. In the
event of the resident's death items are to be returned to the next of kin or
financial representative on production of identification and original receipt.

In order to maintain confidentiality only the Home Manager, Deputy and
Administrator may have access to the safe keeping log information.

Insurance
Resident's personal belongings of value kept in their own room are at their

own risk and should be covered by personal insurance.

3.2.2

Accidental damage to and/or loss of valuables are excluded.

3.2.3. Valuables are:

a) Curios, pictures, or other works of art.

b) Stamps, medals, or coin collections.

c) Articles of yellow coloured metal, white coloured metal, or other
precious metals.

d) Jewellery, fur, clocks, or watches.

The Home Manager must bring this to the attention of prospective
residents.

4.0 Belongings which are considered ‘hazardous’ and / or could result in
harm

4.1 It is recognised by Roseberry Care Centres that Residents may wish to bring
items from home into the Care Home. We would always try to accommodate these
iems but on occasion it may be necessary to prevent these items being brought into
the Care Home or the timing of their acceptance into the Care Home may need to be
negotiated. Such occasions may include:

a) Electrical items need to be either visually checked for their safety if items
are new or Portable Appliance Tested if used; therefore, these items will not be
accepted into the Care Home out of business hours as the personnel responsible for
these checks does not work outside of office hours

b) Items which may present as a falls / trip hazard, for example rugs / mats or
large items which may restrict the usable floor space in a bedroom.

4.2 The Person in Charge on the day of admission is responsible for conducting a
risk assessment of the items brought into the care home. This should include an
assessment of furniture and electrical items; taking into consideration the size of
items of furniture and television sets which may cause a hazardous environment in
which to deliver care. For example, a large sideboard may restrict the turning circle
of a hoist needed for moving & handling, or a large TV may balance unsafely on a
standard chest of drawers. Further to this risk assessment, which must be recorded
in the Residents care plan, and in conjunction with the Residents where able,
relatives may be asked to remove items from the Care Home.

4.3 Consideration should also be given to the Residents level of mobility and risk
of falls. We recognise that mobility and risk can change throughout a Residents stay
in a Care Home and therefore it may be necessary to ask for items to be removed
from a Residents room should a risk be identified.

5.0 EQUALITY IMPACT ASSESSMENT

5.1. All relevant persons are required to comply with this policy and must
demonstrate sensitivity and competence in relation to diversity in gender,
marital status, race, ethnic origin, colour, nationality, national origin, disability,
sexual orientation, transgender status, religion or belief, age, membership of a
Trade Union or political affiliation or because you are pregnant or on parental
leave.

If you, or any other groups, believe you are disadvantaged by this policy
please contact the Regional Operations Manager for the Care Centre, or for

non-Care Centre based staff, contact your manager. Roseberry Care Centres
will actively respond to the enquiry.

R

Roseberry Care

Prevention and Management of Falls

Policy team: Operations

Review Date Reviewed Sections
August 2019 Review
21.12.20 Reviewed 3.1.3, 3.3.4

Added 3.1.11, 3.5.3

Next review date 21.12.21

Policy CA-PR-16

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

1.0
41

1.2

1.3

1.4

2.0
2.1

2.2

2.3

2.4

2.5

2.6a

POLICY

Itis Roseberry Care Centres policy to ensure the welfare and safety of Residents, Staff
and Visitors by providing a safe environment for all, which includes that processes will
be in place to reduce the risk of slips, trips or falls.

Falls are not uncommon in the older population, and therefore, there is an increased
tisk in a Care Centre setting. Falis occur in Care Centres for a number of reasons such
as when Residents do not always utilise their walking aids or use them inappropriately,
or they may be suffering from an infection which may cause confusion and
disorientation.

The World Health Organisation (WHO) define a fall as ‘an event which results in a
person coming to rest inadvertently on the ground or floor or other lower level’.
When Residents are ‘found on floor’ it should be assumed as a fall unless it can be
confirmed as an intentional act. It is not always possible to prevent all falls, but it is
possible to implement processes and plans of care that can reduce risk (Patient Safety
First: The ‘How To’ Guide. Reducing harm from falls. NPSA, 2009 — reviewed 2013).

Each Care Centre will have details of the local falls team which will be easily available
and current to ensure accurate referral as required.

RESPONSIBILITES

The Home Manager is responsible for the implementation of this policy and for
ensuring that all staff read the policy and sign to confirm they have read and
understood the contents.

The Home Manager is also responsible for ensuring that staff access Falls
Management Training and Moving and Handling Training, which are updated annually.

All Care Centres should have a Falls Champion who will take responsibility for
supporting staff and Residents to maintain a safe environment, and who will keep up
to date with latest research and best practice in the prevention and management of
falls and cascade this information across the Care Centre.

The Home Manager will conduct a daily walk round (as per the Quality Assurance
Schedule), during which they will address any issues identified that may contribute to
the risk of slips, trips and falls.

The Home Manager is responsible for ensuring that they sign off any accident forms
which may be completed following a fall. They are also responsible for investigating
the fall and implementing any changes in practice to minimise the risk of a repeat
incident, and to cascade this to staff. Any changes in practice in the management of
falls will be discussed and recorded as a ‘lesson learnt’ in the local Governance
Meeting (as per the Quality Assurance Schedule).

The Home Manager is responsible for monitoring and recording all falls in the Care
Centre each month as part of the Clinical Performance Indicators (CPlIs) and for
producing a falls analysis which will inform the need for any specific response relating
to an individual Resident and the management of their falls and inform any change in
practice. Any changes in practice in the management of falls will be discussed and

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

2.6b

2.7

2.8

3.0

3.1
3.1.1

recorded as a ‘lesson learnt’ in the local Governance Meeting (as per the Quality
Assurance Schedule).

The Home Manager is responsible for sending the falls analysis to the Regional
Operations Manager each month end in accordance with the Quality Assurance
Schedule. The Regional Operations Manager is responsible for conducting a regional
review of falls and alerting the Director of Operations & Compliance of any high-risk
residents or factors which increase the risk of falls occurring. This information is shared
at the Group Care and Clinical Governance Meetings.

In the absence of the Home Manager, the Deputy or Person in Charge will be
responsible for points 2.1-2.6 (inclusive).

All staff are responsible for ensuring risks are reduced and that Residents are given
the assistance they require as per policy.

PROCEDURE
Risk Assessment and Care Plans

A falls risk assessment will be undertaken at the pre-admission assessment that is
undertaken prior to any Resident being admitted to the Care Centre; this includes
permanent and respite admissions.

The falls risk assessment will include:
Individual’s falls history and current mobility, including any aids used
Individuals safety in bed and any history of falling out of bed
Nutrition and Hydration status of the individual
Medication, paying attention to any medications that may cause drowsiness
The individual's cognitive function
The individual's vision and any impairment — are they able to see objects clearly?
The presence of any infection

Upon admission a Care Plan will be formulated in collaboration with the Resident
(and/or Relative/LPA/Representative) if possible, If the Resident's risk assessment
indicates a moderate to high risk of falls then a specific care plan will developed and
close observation and monitoring will be carried out; the frequency of these checks will
be determined by risk and detailed in the care plan. Observation and monitoring will
be conducted a minimum of hourly and recorded on the Observation and Monitoring
form. The care plan will be evaluated monthly, or more often if the Resident has a fall,
and other interventions considered as required.

. Falls risk assessments will be evaluated monthly and at the time of a fall; if the risk

increases this will be reflected in the care plan and risk assessment. If a Resident's
safety in bed is already a risk or becomes a risk, bed rails may be considered as an
option to improve safety. A bed rail assessment will be undertaken which will
incorporate the risk that bed rails can cause — asphyxiation or entrapment (if capacity
is in question a capacity assessment will be undertaken and if the Resident is deemed
not to have capacity to make a decision regarding bed rails a Best Interest meeting will
take place).

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

3.1.5

3.1.9

Residents should be supported to access chiropodist interventions (which should be
recorded on the Dental, Optical and Chiropody recording document) to support good
foot care.

If a Resident has three consecutive falls a referral will automatically be made to the
falls team; this may differ in some local authorities so reference to the local policy
should also be considered.

Staff will ensure that the Resident’s mobility aid (if they have one) is accessible for
them to reach so that the risk of over-reaching and subsequent fall is reduced. Staff
should ensure that any mobility aids are in good working order and clean.

If a resident has a wheelchair assessed and assigned for their use, staff will ensure
the use of any lap strap is risk assessed and forms part of the falls risk assessment
and falls care plan.

Staff will also encourage and support Residents to wear appropriate footwear that fit
and are in good condition.

3.1.10 Staff will ensure that the Resident's call-bell and any personal items they may want or

need, such as spectacles, tissues, books, and drinks, are within reach so that the
Resident does not have to overreach, which will increase the risk of failing.

3.1.11 The Care Pian will be detailed to include whether the bedroom door will remain open

3.2.

to improve levels of observation of those residents assessed at high risk of falls

Management of a fall

3.2.1. When a Resident is found on the floor it should be assumed that they have fallen

unless they state they have put themselves there or have been seen to put
themselves on the floor.

3.2.2 The Resident should be assessed to ensure that the airway, breathing, and

circulation are not impaired.

3.2.3. The person who is first at the scene of the fall should then raise the alarm.

3.2.4 The person in charge will check the Resident for injury and decide as to whether

to support the Resident from the floor. If they are not sure they will call 111 for
advice. If there is evidence of a serious injury, such as a head injury or possible
fracture, the Resident will not be moved and will be kept warm and offered
reassurance by staff whilst the Person in Charge rings 999.

3.2.5 Ifaresidentis prescribed an anticoagulant medication, then medical advice should

be sought even if there is no obvious sign of injury; in most cases the Resident will
be transferred to hospital for opinion.

3.2.6 _ If there is no evidence of serious injury and it is safe to support the Resident from

the floor, following a risk assessment at the scene, staff should support the
Resident using approved methods of moving and handling and following the
Resident’s current care plan regarding moving and handling.

3.2.7. An observation chart will be commenced for 24 hours after all falls. This will

monitor any changes in movement, pain, discoloration of tissue etc.

3.2.8 An accident report will be completed as soon after the event as possible, which

will include a body map.

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3.2.9 Residents will be encouraged and supported to participate in activities which

3.3
3.3.1

3.3.2

3.3.3

3.3.4

promote balance, mobility, and posture.

Equipment
Footwear

Slip resistance relies upon maintaining a suitable combination of footwear and flooring.
The choice of footwear is therefore an important part in preventing falls. It is vital that
Residents wear footwear that is both properly fitting and compatible with floor surfaces.
Particular attention should be paid to those Residents who have problems with their
feet. It is good practice to encourage Residents to wear footwear that provides a sole
with good grip and an adjustable fastening (such as Velcro) to ensure good fit.

Mobility Aids

There is a range of equipment that can be provided to help mobility; mobility aids
require adjustment to meet a Resident's individual needs. It is therefore essential to
have in place a system to ensure that such equipment can be easily identified and
used only by the designated user.

Personal adjustments (for example, walking frame height) must only be made by a
suitably qualified person. A system by which adjustments can be checked to confirm
they are correct is advisable. Mobility aids must be readily available, particularly at
times of most need and close to beds and seating. Remember that one person's
mobility aid can become a trip hazard to others.

Hip Protectors

Hip protectors consist of a specially designed pad made up of an outer shield of
polypropylene with an inner lining sewn or placed into special cotton Lycra underpants.
The pad helps to absorb and spread the impact of a fall. NICE guidance suggests that
more research is required into the effectiveness of hip protectors. They are thought to
be particularly useful for frail, thin, older people who do not have substantial fat layers
which are known to protect bony areas during impact. The garment must be worn 24
hours a day to be effective and there have been some problems with acceptance by
users. When used, the hip protectors are washable at up to 40°C and can be worn with
a continence pad. There are three types of protector currently available in the UK.

Hip protector pads are most suitable for residents who are at high risk of repeated falls
and at risk of fracture — especially if they have osteoporosis. They should only be used
as part of a multi-factorial falls reduction management plan — they should not be
considered in isolation.

Sensor Mats

Sensor mats should be used if the Resident is at risk of falling when rising from bed or
their chair and sustaining injury. The use of a senor mat will be discussed with the
Resident (where possible). If capacity is in question, a capacity assessment will be
undertaken and if it is deemed that the Resident does not have the capacity to make
this specific decision, a Best Interest Meeting will take place. Once a sensor mat is in
situ it will connected to the wall plug by a ‘Y’ connector which will enable the Resident
to also use the call bell system; the sensor mat will be checked daily to ensure it is in
good working order; this will be recorded on the handover document. On applying
pressure to the mat by standing, the staff will be alerted that the Resident is attempting
to stand and or mobilise. Sensor mats will be checked to ensure they are plugged in
and working on each observation and monitoring check — the frequency determined by

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

3.3.5

3.3.6

3.3.8

3.3.9

risk and detailed in the care plan. The check will be recorded on the Observation and
Monitoring form.

High Low Beds

High Low beds should be used where a Resident is at risk of falls due to needing
assistance with mobility and would attempt to get out of bed unaided. These beds are
to be no more than 14 inches off the floor when the Resident is left alone in it. The use
of these beds will be discussed with the Resident where possible (and/or
Relative/LPA/Representative). If capacity is in question, a capacity assessment will be
undertaken and if it is deemed that the Resident does not have the capacity to make
this specific decision, a Best Interest Meeting will take place. These beds have remote
controls, and the remote control should not be left with the Resident if there is a risk of
them raising the bed to an unsafe height. High Low beds will be checked as per
Resident of the Day to ensure they are in good working order.

Crash Mats

Crash mats are used to reduce the risk of injury following a fall from bed. The bed
should be as low as possible when in use as this will lower the risk of fracture if a fall
occurs. The crash mattress should be >50mm in depth. They should be made of a
high-density foam and have a waterproof cover that can be wiped clean.

Profiling beds and integral rails

Telescopic metal rails will not be used in the care centre. If a Resident is deemed to
be at risk of a fall from the bed due a history of falls from bed, then the equipment
above (3.3.5) should be tried first. If these fail, then a profile bed with integral rails
should be used. The use of bed rails and bumpers requires risk assessment, including
the risk of asphyxiation or entrapment. The use of bed rails will be discussed with the
Resident if possible (and/or Relative/LPA/Representative). If capacity is in question, a
capacity assessment will be undertaken and if it is deemed that the Resident does not
have the capacity to make this particular decision a Best Interest Meeting will take
place. The bed rails will be checked at each intervention and any issues reported
immediately to the Maintenance Department. The bed rails will also be checked as per
Resident of the Day.

Straps and harnesses

It may be necessary to implement the use of lap straps to prevent a Resident from
falling from a wheelchair whilst mobilising. The use of a lap strap will be discussed with
the Resident if possible (and/or Relative/LPA/Representative). If capacity is in
question, a capacity assessment will be undertaken and if it is deemed that the
Resident does not have the capacity to make this specific decision, a Best Interest
Meeting will take place. The lap strap will be checked for safety at every use. Details
of when to fasten the lap strap will be recorded in the corresponding care plan.

Helmets

A helmet is a form of protective gear worn to protect the head. Protective headgear
reduces the risk of head injury for Residents with poor balance or equilibrium, seizure
disorders and those prone to self-injurious behaviours such as head banging.
Protective headgear is designed to absorb shock and redistribute impact on contact.
The use of such protection will be discussed with the Resident if possible (and/or
Relative/LPA/Representative). If capacity is in question, a capacity assessment will be
undertaken and if it is deemed that the Resident does not have the capacity to make

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

3.4
3.4.1

3.4.2

3.4.3

3.4.4

3.5
3.5.1

3.5.2

3.5.3

3.6

this specific decision a Best Interest Meeting will take place. Referral to
GP/Occupational Therapist should be made to arrange for the appropriate protection.

Whichever measure is used, the care plan and risk assessment will detail when and
where the equipment is used.

Falls Reporting and Monitoring

Following a fail, the person in charge should complete an incident report immediately
following the fall.

The person in charge will ensure the fall and details of action taken is reported to
Relatives. Ifa Resident is admitted to hospital following a fall, every effort will be made
to contact the Relatives/LPA/Representative to provide details of which hospital their
loved one has been admitted to.

If the fall has resulted in a Resident requiring hospital treatment, the Home Manager
(their Deputy or Person in Charge in the absence of the Manager) will notify the CQC
and consideration should be given to submit a Safeguarding form and or RIDDOR form
following discussion with the Regional Operations Manager. The Regional Operations
Manager will be informed by the Home Manager (their Deputy or Person in Charge, in
the absence of the Manager).

The Home Manager will investigate the fall and record their finding in the relevant
section of the Accident/Incident Form. All falls will be included in the monthly Falls
Analysis and form part of the monthly Clinical Performance Indicators which will inform
any trends and changes in practice that may be required across the Home or change
in interventions for a particular Resident. Changes in practice will be cascaded by the
Home Manager and discussed at the local Governance Meeting and recorded under
‘lessons learnt.’ The care plan will be updated accordingly.

Near Misses

A near miss is an unplanned event that has the potential to cause but does not
actually result in human injury, environmental or equipment damage, or an
interruption to normal operations.

During a review of accident forms, near misses should be considered and any
interventions discussed at Health and Safety Meetings. It should be clearly marked
as a near miss on all forms.

Near Misses should be reviewed at the time of the fall and at each month end to
consider if lessons can be learned and changes to practice implemented to reduce
the risk of a further near miss.

Training

All care, nursing, management, and operational staff will complete online Falls
Management training annually. In addition, all care, nursing, management, and
operational staff will attend face to face Falls Management Training every two years.

Roseberry Care Centres Management of Falls Policy v4 Dec 2020

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Bibliography:

National Patient Agency: Slips, Trips, Falls in Hospital; London, NPSA, 2010
NICE - Delirium — diagnosis, prevention, management; Clinical Guide 103, 2010
References

Patient Safety First - The ‘how to’ guide, reducing harm from falls; NPSA 2009

World Health Organisation (2018)

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