Care home initiative reduces falls without curbing residents’ activities
An award-winning clinical manager's initiative has embraced positive risk and reduced falls among care home residents, allowing them to pursue activities they enjoy
An award-winning clinical manager's initiative has embraced positive risk and reduced falls among care home residents
- Falls improvement project is being rolled out in 20 care homes
- It is based on research that identified 12 risk factors for falls
- Aim is to reduce the human cost of falls as well as financial costs
An individual falls risk factor assessment and care plan introduced by Lindsay Rees reduced the number of falls in a pilot project and helped her win the Nursing Older People category of the RCNi Nurse Awards 2019, the profession’s top accolade.
‘When an older person falls it creates a tremendous cost,’ says Ms Rees, Colten Care's clinical manager for 20 care homes in the south of England.
‘There is the obvious financial cost, but it is the human cost in the form of pain, distress, loss of confidence, time spent in hospital away from loved ones and loss of independence that I want to reduce.’
Her answer is a falls improvement project that focuses on ensuring residents continue to enjoy activities they love while making sure that the risk of falls around each activity is minimised.
The project reduced the number of falls in a pilot in two homes and is enjoying a successful rollout in the care home operator's 20 homes.
What the judges said
Judge Caroline Shuldham, chair of the RCNi editorial advisory board, says: ‘Lindsay’s initiative succeeded not only in reducing the incidence and burden of falls in her care home residents and making the environment safer, but achieving this while maximising residents’ personal freedom and opportunities to pursue activities they enjoy.
‘The judges were impressed by the careful and logical approach Lindsay adopted, thus ensuring staff engagement and support for the project and contributing to its success.’
Ms Rees says: ‘Part of my role is to ensure that staff provide an exceptionally high standard of evidence-based clinical care for our 1,000 frail and older residents, but I was aware the falls risk assessment in use was not up to date with best practice.’
She decided to address this with a quality improvement project in two homes – one a nursing home and the other a dedicated dementia community.
Why, when and where
After conducting an in-depth literature review of best practice in falls management, Ms Rees developed a range of resources including an individual falls risk factor assessment and care plan based on 12 risk factors she identified through her research.
She has also designed resources to help staff reflect on why, when and where people are having falls. These include posters for fall-free days, falls location mapping and the use of falls huddles, guided by a falls analysis document.
‘This is where my nursing background comes in,’ says Ms Rees. ‘Reflection is so important and powerful. Hopefully this project has helped nursing home teams understand the world around them better and have the light-bulb moments that will enhance their residents’ lives.’
Poem used in training
Helping staff to appreciate the effect they can have on falls risk reduction was the biggest challenge, she says. Her training stresses to the care team how the implications for someone aged 80 who falls are much more severe than those for a younger person.
‘I highlight the impact by using a poem, The Last 1,000 Days by Molly Case, in training sessions,’ she says.
‘The poem emphasises that the time spent in hospital waiting for tests and treatment is precious time lost for patients, who are away from the people and things that are important to them. It highlights that for a person who is in their last 1,000 days of life, this wasted time is particularly painful.
‘As the average length of stay in a nursing home is less than 1,000 days, this concept was particularly meaningful for the residents the staff were caring for, and the staff found it powerful.’
Throughout the project, Ms Rees visited the homes regularly and provided weekly feedback on the number of falls and individual residents’ risk factor management.
She consulted home managers and clinical leads throughout and incorporated their feedback into the resources.
Jackie Cash is clinical lead at the nursing home that took part in the pilot – Braemar Lodge in Salisbury.
‘Before the pilot, a fall would be recorded but there was not as much action around it,’ she says. ‘Now, if a resident falls twice in four weeks the nursing team looks at it much more deeply.
‘The education programme has empowered the nurses to become even more proactive in finding solutions. Before, I might have discussed a fall with the overnight nurse when I came on in the morning, but now there will be actions in place before I arrive, for example assistive technologies may be being used.’
Falls plotted on a map
Every day the team looks at any falls and plots them on a map of the home to see if there is any correlation between them. ‘There might be more than one fall in a corridor, so we will look at staffing perhaps,’ says Ms Cash.
‘Our staff were already well-educated and aware of falls risk, but this project has fine-tuned our approach’
Jackie Cash, clinical lead
‘The 12 factors in falls are known and have led to more thorough assessments. This has helped to identify reasons for falls that had previously been missed.
‘Significantly we identified two women with postural hypotension through the project by monitoring their blood pressure when they were lying down and standing up.’
‘You can always improve on care’
Most importantly, the nurses look at the individual and how they can maintain independence. ‘Our staff were already well-educated and aware of falls risk, but this project has fine-tuned our approach,’ says Ms Cash. ‘You can always improve on care, and our staff have embraced this.’
‘Residents are at the heart of it. We asked them to complete a survey at the beginning of the project about their well-being and their fear of falls, asking them how they feel when they get up from sitting down, for example.
‘It made them understand the risks better and how to help themselves to be well and carry on with the things they love to do.’
More complex reasons for falls
During the 24-week pilot the nursing home recorded a 37% reduction in falls.
The pilot proved more challenging in the dedicated dementia community, where the residents were severely frail and the management team was not stable during the project.
‘I am flying the flag for nursing home nurses – we are showing the NHS how it is done’
‘Residents had less capacity to understand their care and care planning,’ says Ms Rees. ‘The reasons for their falls were more complex. Also, the clinical lead who I began the project with left after a couple of months, which meant starting again and engaging with a new clinical lead, running the training again and doing more sessions and building up the relationship with the home staff.’
‘Circumstances are not always on your side, and that is part of the evaluation – understanding why it didn’t work and whether you can solve or change barriers. There is no point in keeping trying if nothing has changed or can be changed.’
The relaunch in the dedicated dementia community has been a success, however, with falls showing a 35% drop per week.
At the nursing home, the improvement is not only being sustained but the number of falls has reduced even further by 53%. Data from the first home in the roll-out show a 42% decrease in falls.
Winner of top accolade
Ms Rees was named this year’s winner of the Nursing Older People category of the 2019 RCNi Nurse Awards.
She hopes her award will generate opportunities to work collaboratively with nurses in other care homes to share best practice and awareness and focus on risk management.
‘I am so excited and proud to win this prestigious award,’ she says. ‘As a nurse who left the NHS 12 years ago and works in the private sector in nursing homes, I am flying the flag for nursing home nurses. We are showing the NHS how it is done.’
Living life to the full
She wants to raise the profile of nursing home nurses, to make it a sought-after setting for nurses to work, because that will benefit the older people they care for.
‘Residents living in nursing homes need skilled clinical leaders to manage and deliver their care,’ she says. ‘We want dynamic clinicians who can lead and keep older people out of hospital, living their life to the full and dying well, comfortably and pain free.’
Positive risk approach means lives are not limited by frailty
The falls risk assessments and falls analysis resources are designed to ensure, as much as possible, that residents’ lives are not limited by their frailty.
‘The positive risk approach is part of the training,’ says Colten Care clinical manager Lindsay Rees. ‘This is not about stopping falls but enabling people to do what they want to do in a meaningful way and in the least restrictive but most safe way.’
Love of gardening
She gives the example of a woman aged 92 in a nursing home who wears a badge identifying her as the assistant gardener. ‘We know there is a risk of falls,’ says Ms Rees.
‘And she has fallen in the garden more than once and had to be picked up out of a bush. But her enjoyment is high and having that job description is very important to her.
‘The falls project is not stopping her, but we looked at trip hazards to allow her to continue. By being allowed to continue to work in the garden she maintains her physical health and mobility.’
The clinical lead at the resident’s care home, Jackie Cash, adds that they took the woman on a park run. ‘And she completed it!’ she says.
Ms Cash says the positive risk approach is essential in giving residents choice in the way they live their lives and supporting them to exercise.
‘We’ve recently taken residents ice skating and this weekend we made the wish of a 105-year-old come true and organised for her to go out on the back of a motorbike, riding pillion just as she did with her husband.’
In another case in the home, the falls huddle led to an unexpected approach to preventing one man’s frequent falls.
‘The man had Parkinson’s disease and was having falls as he walked around the home,’ says Ms Rees. ‘The home had tried everything, spoken to the GP and the man’s family had brought in non-slip shoes.
‘It was considered at a falls huddle and a carer said that while the shoes were non-slip and in theory safe and gripped the floor, this was a problem because of the way the man shuffled as he walked.
‘So his family brought in some slippers and the man could slide around and stopped falling. It was a counterintuitive but effective solution to the problem.’
Meet the other finalists in the Nursing Older People category
Anne Sanderson, NHS Lothian
Community bladder and bowel nurse specialist Anne Sanderson’s in-reach project has ensured that patients return home from hospital more quickly and prevented a rise in the number of those with hospital-acquired incontinence
Dementia team, Royal Trinity Hospice, London
Dementia team members Nuno Santos Lopes, Sarah Priestley and Karen McIvor have reduced unnecessary hospital admissions and made it possible for 69% of people with dementia to die in their preferred place
Suzanne Thomas, Cardiff and Vale University Health Board
Trauma nurse practitioner Suzanne Thomas has improved pain assessment and management of older people with hip fractures. Her project saw the administration of pre-operative pain relief rise to almost 100%
Reach team, Northern Health and Social Care Trust
The Reach initiative supports nursing home staff to address issues such as deteriorating urinary symptoms, winter pressures, diabetes and end of life care. Average emergency department attendance per home has fallen as a result
For more details go to nurseawards.co.uk