Quality and Excellence in Specialist Dementia Care (QESDC): baseline one-off self-assessment tool and reporting arrangements

NHS Boards undertook a one-off baseline self-assessment of current practices in all specialist dementia care settings to meet the needs of Commitment 11 and address the issues raised in the Mental Welfare Commission report 'Dignity and Respect: dementia continuing care visits'. This report summarises those self-assessment returns to identify common areas of practice.

Outcome 8. Safe and effective care - falls care

Where avoidable, people with dementia do not fall during their stay in hospital. A systematic process is in place to assess people for the risk of falling (which includes medication review) and individualised controls are implemented to prevent falls or reduce any risk to a minimum.

Actions on falls care across the boards tend to focus on audit, risk assessment, compliance with national and local guidance, environmental adjustments, appropriate recording and, where necessary, physiotherapy referral. Prevention measures such as the Scottish Patient Safety Programme Falls Care bundle, the Fallsafe bundle and the Clinical Quality Indicators are commonly used.

There is awareness throughout the boards that the causes of falls are complex and that older people accessing mental health services are particularly vulnerable because of dementia or depression, side-effects from medication and/or problems with balance, strength and mobility. There is also a pressing need to reconcile the natural inclination to protect patients from risk of falls by restricting their mobility and independence with the requirement to respect and promote their rights, wishes and quality of life. Patient safety and actions to reduce falls need to be balanced with ideas of independence, rehabilitation, personal choice, privacy and dignity.

The NHS Grampian approach to risk assessment begins at admission. All newly admitted patients undertake a falls risk assessment and a patient risk-management and handling plan is developed. The assessments, which must be completed within the first 24 hours, take into account not only the risks to, but also the strengths of, the individual patient, detailing what he or she is able to do as well as issues that may require interventions. This allows for safer risk enablement. All patients with a high risk of falls are referred to a physiotherapist and are discussed with medical staff.

The team takes a positive approach to risk and supports risk enablement through working with physiotherapy, occupational therapy and visual impairment teams, using mobility aids appropriately and deploying equipment such as bed sensors and telecare. All nursing staff receive mandatory falls-risk training from a physiotherapist, including discussion of environmental issues that increase falls risks. Wards are kept clutter-free and signage is used to indicate wet floors and other hazards.

NHS Ayrshire & Arran has a bone-health and falls-prevention strategy in place, aligned to the National Falls Pathway and Delivery Framework for Adult Rehabilitation. The model has five principle tiers spanning community and hospital provision and aims to deliver a whole-system approach to anticipatory care for falls prevention and bone health. Locally, attention is given to issues such as ensuring flooring design accommodates the difficulties some people with dementia experience in relation to depth of perception.

Falls prevention is a strategic priority for NHS Fife. The Scottish Patient Safety Programme bundles approach is being used to provide a framework to deliver improvement activity. A frailty screening tool that includes falls-screening questions is completed on admission for each patient, after which the falls pathway is followed. The aim of the approach is that by the end of 2015, falls in hospital will be reduced by 25% and emergency admissions of people aged 65 and over for falls will be reduced by 20% (by April 2015). Hip fractures will be reduced by 5%.

Improvement work in NHS Borders led to an overall 54% reduction in falls incidents between May 2011 and April 2014. The board recognised in 2011 that a 14-bed older-adult continuing-care ward for patients with dementia had the highest falls incidence in the board area. The ward team began improvement work in collaboration with the Falls Lead, fully recognising the complex factors in dementia that affect the risk of falling but also aiming to reduce the number of falls and the level of harm sustained by patients. Active trend analysis identified the time of day and locations in the ward in which falls were occurring: staffing levels were consequently reviewed and an activity coordinator role introduced. Patients at high risk of falling were identified and active interventions put in place to modify risk factors. A falls log was developed to capture activity concisely.

Other measures included the identification of falls link nurses, development of a training programme, performance of environmental and lighting assessments, and the introduction of bed sensors. Use of the Scottish Patient Safety Programme Falls Care bundle commenced in November 2013, with reinforcement of the NHS Borders post-fall protocol. The result of this collective improvement work was a reduction in falls from almost 500 between May 2011 and April 2012 to 225 over the equivalent period in 2013/2014.

An enhanced falls care-rounding programme has been introduced on the wards in NHS Lothian.


Email: Ian Roxburgh

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