TDSAP Falls and safeguarding – Guidance for organisations who provide care and support

1. Introduction

1.1 This guidance is produced on the best available understanding of the issues; however, organisations that provide care and support should also refer to the latest CQC guidance, and if necessary, their own legal advice, in more complex matters.

1.2 This guidance is relevant to all providers of health and social care services to adults in Torbay and Devon to enable organisations to understand when a safeguarding adult concern to Torbay and South Devon NHS Foundation Trust or Devon County Council is required.

1.3 This guidance is in addition to, and does not preclude all organisations from adherence to, their own specific policies and guidance relating to falls and incident management, along with any other relevant legislation, policy, and guidance.

1.4 Many safeguarding adult concerns are raised to Torbay and South Devon NHS Foundation Trust and Devon County Council concerning falls; however, it is recognised that not all falls will need to be raised as a safeguarding concern. This document, therefore, is intended to be a guidance tool to promote best practice
in understanding when a fall may need reporting as a Safeguarding Adults concern.

1.5 This document should be used in conjunction with professional judgement and is not a substitute for the policies and procedures required of organisations who provide care and support services to ensure safe care.

1.6 Where there is any doubt whether to raise a Safeguarding Adults concern, staff should always speak with the safeguarding lead or equivalent within their organisation. If further advice is needed, consult with the relevant Safeguarding Adult Service as provided by Torbay and South Devon NHS Foundation Trust or Devon County
Council.

1.7 Where a fall has taken place in a hospital, if following NHS internal processes there remains doubt as to whether a safeguarding referral should be made, then guidance must always be sought from the Safeguarding Adult lead within the hospital and/or the Safeguarding Service as provided by Torbay and South Devon NHS
Foundation Trust or Devon County Council.

2. Responsibilities of organisations who provide care and support services

2.1 Prevention of harm is one of the six key principles of adult safeguarding. Organisations who provide care and support services are expected to put in place measures to reduce the risk of falls, and harm from falls, for every person they support.

2.2 Key to prevention and management is first identifying the person’s specific risk of falls or risk of harm from falls (for example, high likelihood of fractures if the person has osteoporosis). Pre-admission assessment should consider the risk of falls, and how to manage the risk before a change takes place. This should include relevant history as well as looking at potential risks in the new environment, followed by personalised care planning to manage those risks.

2.3 The provider of care has a duty of care to protect the clients they support and staff from risks relating to physical assistance. Moving and handling policies must be up to date and all staff must have relevant training to minimise risk associated with moving and handling. Equipment used for moving and handling must be regularly checked according to appropriate guidance and kept in safe working order. Clients should be assessed individually for any proposed use of equipment to support moving and handling with the staff group operating such equipment trained and confident in using the equipment to support the moving and handling of the client.

2.4 Accountability is another one of the six key principles of adult safeguarding. This encourages accountability and transparency and therefore all falls should be
reported in line with:

internal organisational policies and procedures supporting staff who provide care and support services around management of incidents
any contractual requirements (e.g., CQC, TSDFT, DCC, CHC, ICB)
legal and regulatory requirements (including RIDDOR, health and safety)
safeguarding adult’s policy, where indicated
accountability within professional codes of conduct (e.g. NMC, GMC, SWE)

2.5 Please note that any internal/company reporting processes must not delay safeguarding reporting where it is required; both can be done at the same time. It is best practice where organisations triage falls through managers to have clear guidance for staff on when and how to escalate for immediate or quick decisions, for example at weekends, or out of hours.

2.6 Falls need to be documented and checked against organisational risk assessments and quality audits. Organisations that provide care and support services may also be asked to report on falls to the Integrated Care Board (ICB), Care Quality Commission (CQC), Torbay and South Devon NHS Foundation Trust / Devon County Council Quality Assurance and Improvement Teams or through other routes (e.g., RIDDOR/Steis).

3. Best Practice for the management of falls

3.1 Individual assessments and care plans should be reviewed and updated as a minimum every month, and the falls risk assessment (including environmental risk assessment) and any associated management (care) plan should be reviewed every six months as a minimum; and

3.2 There should be a complete review of both the assessment and care plan:

on preadmission and upon admission
following a fall
when there is a significant change in a person’s condition for example, during/following illness or infection, change in medication, diagnosis of postural hypotension
on transfer from another care setting for example, discharge from hospital
if a falls assessment with interventions has been made by an external team

3.3 Falls records are essential in falls management and should be completed for every fall that happens. A designated staff member should review and analyse the information so that possible causes can be identified, preventative measures put in place, or further referrals made. This should include checking for any safeguarding issues.

3.4 All members of the care/support team should be aware of, and involved in, the assessment, care planning and evaluation of risk of falls and have an ongoing responsibility for ensuring agreed management plans are implemented.

3.5 Other appropriate professionals for example, GP, community nurses, falls team, physiotherapy, occupational therapists, and dietician, should be involved as and when required, and their advice recorded and followed.

4. Post-fall Protocol

4.1 A clear post-fall protocol should be in place to support staff in taking the right action when a fall has occurred, this could include following locally agreed pathways as well as comprehensive information and guidance around falls prevention, and appropriate training of staff.

4.2 Staff should receive guidance and training to ensure that further harm is not caused because of their post-fall intervention.

it is essential that individuals are checked for injury before any attempt is made to move them
medical treatment should always be sought promptly where necessary via GP, NHS 111 or 999 in an emergency
information regarding falls services, including access to appropriate moving and handling equipment, should be easily available to staff, especially outside of standard daytime working hours

5. When to consider raising a safeguarding adult concern following a fall

5.1 All agencies have a duty to raise a safeguarding adult concern to Torbay and South Devon NHS Foundation Trust or Devon County Council if there is a concern that an adult who has needs for care and support is experiencing or at risk of abuse or neglect. This is in addition to other requirements on organisations who provide care and support services around the management of falls.

5.2 There could be concerns that a fall occurred because of abuse or neglect (including self-neglect), or that care and treatment following a fall was abusive or neglectful. Consider if one or more of the following categories of abuse apply:

physical abuse: Someone pushed/hit/tripped/barged the adult which resulted in the fall
neglect & acts of omission: Care plans not followed, checks not completed, failure to assess/recognise and respond to need, for example: where there has been a significant history of falls with no action taken; a long lie occurred due to inappropriate action taken; monitoring during wait for medical response was inadequate and/or not documented; call bells are out of reach or sensor mats not responded to in a timely manner
organisational abuse: Systems have failed to support safe care, for example: lack of staff, untrained staff, care plan reviews not completed, information not communicated effectively; moving and handling documentation incomplete or omitted
self-neglect: Fall occurred because the person is not caring for themselves, or their environment, or refusing help. There will be a need in these circumstances to consider the mental capacity of the person to make decisions to decline support

6. When to raise a safeguarding adult concern following a fall

6.1 Where there is concern about actual or possible risk of abuse (as described above) – not because there is a general concern about an individual’s safety.

6.2 Where an individual sustains a physical injury or harm due to a fall and there is a concern that a risk assessment was not in place, not followed or not updated to reduce risk – the key factor is that the individual has experienced avoidable harm, which is neglect, either by the staff member or the organisation.

6.3 Where an individual has sustained an injury from a fall which requires medical advice or attention, in a timely fashion, and this has not been sought.

7. Examples of falls which may be a safeguarding adult concern

Note: this is not an exhaustive list. Staff should always speak with the safeguarding lead or equivalent within their organisation if in doubt, or contact Safeguarding Adults at Torbay and South Devon NHS Foundation Trust or Devon County Council for further guidance:

a fall because of safety equipment not in working order, not being issued or not in place following an assessment of need causing harm (e.g., bed rails – although bed rails can also be a cause of falls or other harm without proper assessment).
repeated falls despite preventative advice being given and a series of minor injuries have been incurred.
fall and injury because of medication mismanagement (e.g., blood pressure or diabetes medication missed, or not receiving antibiotics to manage infection).
falls during assists or using equipment e.g., hoists and slings worn or used incorrectly, falls out of windows that should have opening range limited, sliding out of a chair because of poor positioning.
members of staff not receiving training in falls management at appropriate level and/or not adhering to the falls policy and protocols following a fall.
too few staff on duty to meet the needs of the people being supported safely, resulting in falls.
environmental hazards, such as poor lighting or clutter, equipment left out, wet floors, resulting in a fall and injury.

8. Unwitnessed falls/unexpected injuries

8.1 If a fall is unwitnessed, then it can’t be precisely known how the person came to be on the floor. It is possible that they were pushed or knocked over by someone else, or something else has happened.

8.2 In these cases, each incident needs to be considered as carefully as possible, using any known history or information, and a judgement made as to the most probable cause. Not all unwitnessed falls will be because of abuse or neglect and therefore required to be reported as a safeguarding adult concern.

8.3 Recording the detail available to consider possible cause and what action has been taken will be even more important where direct cause cannot be definite. Body mapping should be included with date/time/place/signature of person completing documentation. Where there remains a high level of uncertainty, or if significant injury, report as a safeguarding adult concern.

8.4 It is not always necessary to raise a safeguarding adult concern if a person say that they fell, even if it was not witnessed. If the person can explain what has happened, then abuse/neglect is not likely if:

they have no impairment which would cause doubt about their story, and
there is a up to date risk assessment in place, and
the post-fall protocol, including observations, has been followed

8.5 In circumstances where a person has sustained an unexplained injury, senior staff should make a judgement based on the evidence available to determine what may have happened and whether a safeguarding adult concern should be raised. In these circumstances it may be more helpful to use the term ‘unexplained injury’ rather than ‘unwitnessed fall’.

8.6 However, where a significant or suspicious injury has occurred which is unexplained, or where the person has repeated unexplained injuries, this should be raised as a safeguarding adult concern.

9. Examples of unwitnessed falls which may be a safeguarding adult concern

Note: this is not an exhaustive list. Staff should always speak with the safeguarding lead or equivalent within their organisation if in doubt, or contact Safeguarding Adults at Torbay and South Devon NHS Foundation Trust or Devon County Council for further guidance:

Unwitnessed fall with injury: a resident has dementia and sight and hearing loss. Heard to fall by staff in next door room. Found on floor of their room, believed to have tripped over a stand aid which had been left in the corridor while staff were supporting next door.

Safeguarding adult concern to be raised; possible neglect as staff appeared to have not considered the risk posed by the equipment for residents with dementia and sensory loss; health and safety issue as a trip hazard; RIDDOR notification when applicable.

Unwitnessed fall with injury: a resident was checked regularly through the night as per care plan, on one check found on the floor of his bathroom. He tells staff that he got up to use the toilet, they checked him over before assisting him to get back into bed. He had some pain relief for general discomfort that day but was able to walk around using his frame in his usual manner. A bruise came up on one hand which staff noted and monitored. The next day his hand started to swell, staff supported a GP consultation, and an x-ray was arranged, found to have a fractured wrist.

Not required to raise a safeguarding adult concern: resident has mental capacity and could describe what happened. Evidence that staff supported him correctly, monitored post fall and acted when his needs changed; also, evidence from provider that immediately following the fall, a review was done, and preventative measures put in place. No falls history prior to this.

Unwitnessed fall with injury: staff member supported a resident into bed, became distracted by another resident and left the room without lowering the bed as per falls care plan. The resident fell out of bed, hitting her head and needing hospital admission.

Safeguarding adult concern to be raised; possible neglect, the care provider showed evidence of falls diary, care planning, regular review, MDT involvement so no indication of organisation abuse, but it was possible neglect on the part of the staff member.

Witnessed fall with injury: two staff used a hoist and sling to support a resident from bed to chair in the early morning. Sling strap broke and the resident fell to the ground, causing several skin tears.

Safeguarding adult concern to be raised: possible neglect and organisational abuse. Staff did not check the equipment before using it; the provider had not kept up regular checks of all equipment; risk to other residents identified.

10. Raising a safeguarding adult concern

In the first instance the organisations’ Responsible Person or Safeguarding Lead should be consulted. Should it be determined that a safeguarding adult concern referral is required then this should be made to the relevant Safeguarding Adult Service:

We encourage Safeguarding Adult concerns to be raised via the Torbay and Devon Safeguarding Adults Partnership website Home – Devon Safeguarding Adults Partnership

Alternatively, contact can be made via telephone or email as follows:

For those adults living in Torbay please call the number below or email:

01803 219700

safeguarding.alertstct@nhs.net

For those adults living in Devon please call the number below or email:

0345 155 1007

Email: adultsc.safeguardingadultservices-mailbox@devon.gov.uk

11. What questions are providers of care and support services likely to be asked when raising a safeguarding adult concern to Torbay and South Devon NHS Foundation Trust or Devon County County:

Note: this is not an exhaustive list. Staff should always consider the persons’ views in line with making safeguarding personal and seek consent where possible.

What happened, where, and when?
Was the fall witnessed or unwitnessed?
Does the person have mental capacity to consent to you raising a safeguarding concern?
Is there apparent injury from the fall?
Has a body map/photo (with consent) been completed if injuries sustained?
Has the person been checked by staff for any injuries?
How long was the person on the floor and did a member of staff remain with the person whilst on the floor, including what monitoring was in place whilst the person remains on the floor?
If there is apparent injury, has the person been seen by a medical professional or medical advice sought? How long after the fall did this happen?
If the person has been seen by a medical professional, what is their view on the injury/bruising (e.g., unusual/concerning)
How many falls or similar has the person had in the last 6 months?
When was their last fall? What management plan was put in place after this (e.g., any specialist equipment, referrals to outside agencies, any regular monitoring – consider night as well as daytime monitoring)
If a care plan is in place, is there documentation to show the plan was being followed?
Was the organisations’ post fall procedure followed by staff?
What has been done now to prevent or minimise risk of further falls for the person?
Has the family or advocate been advised of the fall and action taken by the provider?

Appendix 1: Links to further information

Care Inspectorate Falls and Fractures

Guidance Sheets: Page One – One Devon – 05 Medication and falls

NHS Knowledge Anglia I Stumble

PHE Guidance Jan 2020 – Falls : Applying All Our Health

Acknowledgements

With thanks to Norfolk Safeguarding Adults Board whose guidance for providers has been adopted to produce this document.