QI project: Reducing risk of Falls at Baily Residential Care Home, Mansfield, Nottinghamshire
Aim: To reduce by 50% the number of Falls in Baily House Residential Home, Mansfield in 6 months
This Quality Improvement project has been a collaboration between the Care Home Team and Nottinghamshire Healthcare NHS Trust's Falls Team and the staff of a residential care home. All parties were concerned about the level of Falls occurring in this home.
August 2018 - care staff commenced the falls safety cross which would highlight the number of falls per day - staff felt this was just another form to complete. It didn't highlight any trends for times or locations of falls.
September 2018 - The Falls Team Lead from Mid Notts provided Falls Training for Baily House staff.
October 2018 - I introduced the Falls mapping process with the Deputy Manager at Baily House. This involved colour coding shift patterns, having a map of each floor and placing the relevant coloured 'dot' in the location of the Fall.
This simple process highlighted trends in times and location of Falls. Staff at Baily House were then able to make changes to the number of staff available in the dining room at meal times and move the dining tables around to reduce cluttered areas. This process also made staff aware of the 'frequent' fallers and helped them utilise the most appropriate falls sensor equipment for each resident.
There were 3 PDSA Cycles:
PDSA 1 - Staff used a Safety Cross. This enabled staff to capture daily when a Fall has occurred. This test ran for a month and although showed when a Fall occurred it did not show anymore detail.
PDSA 2 - This ran for 7 months and involved providing training for all staff around Falls to look for potential fall causes to gain confidence in Fall prevention and how to record Falls data to make it meaningful.
PDSA 3 - The introduction of the Falls Mapping Tool which allowed staff to mark on a map of the home where the falls have happened, the times that they happened and any coloration to the fall such as staffing levels, furniture or lack of furniture. This cycle ran for 6 months.
