http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/Slips_Trips_and_Falls_procedure

Slips, Trips and Falls procedure

Responsible Directorate:

Corporate Governance

Responsible Director:

Helena Corder

Date Approved Committee

8 August 2008 Governance Committee

Version Control.

Document Title Document number Author Contributors Version Date of Production Review date Postholder responsible revision Primary Circulation List Web address Restrictions

Slips, Trips and Falls 1 Chris Bedford Terry Service, Maria Freer 1 March 2008 August 2010 for Chris Bedford PDG None

Standard for Better Health Map. Domain Core Standard Reference Performance Indicators

1 – Safety, 2 – Clinical & Cost Effectiveness, 3 – Governance, 4 – Patient Focus C1, C5(a) C5(c), C7, C11(b), C13a 1. Issue of document to clinical staff 2. Availablity of training for clinical staff.

3. Number of Incident Reports 4. Action plans related to reported incidents (where applicable)

Contents

Section 1 2 3 4 5 6 7 8 9 10 11 12 Appendices A B C D

Page 2 2 2 3 3 3 4 4 4 4 5 5

Policy Statement Introduction Associated Policies and Procedures Aims and Objectives Scope Accountabilities NHS Kirklees falls pathway Equality Impact Assessment Tool Training needs analysis Compliance monitoring References Stakeholders NHS Kirklees Falls Pathway Community Falls Risk Assessment Training Needs Analysis Equality Impact Assessment

Page 1

1.

Policy Statement

NHS Kirklees is responsible for a range of community based health care services to the residents of Kirklees. This involves providing services from Health Care buildings, Partnership Premises, Care & Nursing premises and within patients own homes.

The Trust attaches the highest importance to the Safety of all staff, patients and those affected by Trust undertakings and recognises that slips and trips resulting in falls are the most common cause of major injuries in the workplace in Great Britain.

The aim is to provide such information, instruction, training and supervision as is needed for the purpose or identifying, reducing and managing any potential or actual falls with patients and staff.

2.

Introduction.

Patient safety is a key focus, especially when providing care and services to older and vulnerable persons. Falls are a particular clinical concern because of the frequency at which they can occur and also because of the physical, psychological and social consequences. Falls are a key focus within the National Service Framework for Older People with Standard 6 aiming to reduce the number of falls which result in serious injury as well as ensuring effective treatment and rehabilitation for those who have fallen, (DOH 2001) Slips, trips and falls are not an inevitable part of the healthcare industry, and can be prevented or reduced through planning and positive management.

The Trust will achieve this by supporting and encouraging management and staff in an environment where they will work together positively and proactively towards embedding a pro-safety culture throughout our organisation.

The Trust supports, and takes direction and guidance from the Health & Safety Executive (HSE), Royal Society for the Protection of Accidents (RoSPA) and the National Patient Safety Agency (NPSA) Associated Policies and Procedures.

3.

This document should be read in accordance with the following Trust policies, procedures and guidance.

• • • •

Health and safety policy Incident reporting policy Claims and complaints policy NHS Kirklees Falls Pathway

Page 2

4.

Aims and Objectives.

• • • • • •

5.

Provide and promote as far as reasonably practicable, a safe and secure environment for all staff, service users, visitors and contractors Assess the hazards and risks to patients and employees from falls, and put in place adequate management arrangements to remove or reduce the potential for harm to occur.

Maintain systems and processes to help to ensure the safety of staff and patients at work Raise falls awareness in the community Make every effort to ensure organisation-wide compliance with appropriate legislation and guidance.

Investigate all reported incidents of falls to identify causation and seek to make changes as necessary.

Scope of the Policy / Procedure

This policy and pathway must be followed by all NHS Kirklees employees and staff on temporary or honorary contracts as well as pool staff and students.

The document is made available for all contractors to use as required.

6.

Accountabilities & Responsibilities

Board Accountability.

The Chief Executive is the accountable officer but delegates the responsibility to the Director of Provider Services for managing appropriate clinical systems and staff in place to manage falls within clinical environments. The Director of Patient and Professions has the responsibility for patient safety and for ensuring that all patient safety incidents are investigated, managed and action taken to remove, reduce or control any potential or actual patient hazards and risks.

Managers All managers have the responsibility for ensuring for taking all reasonable precautions to reduce the potential of falls occurring including ensuring that premises are safe, staff are suitably trained and informed and all incidents are investigated, reported and where applicable, action is taken.

Staff All staff have a professional responsibility for ensuring that patient safety is paramount. Staff must ensure that they take all reasonable actions to identify, reduce or remove any potential causes of falls. This is achieved by noting, reporting and taking action to reduce potential slip or trip hazards, reporting vulnerable or at risk individuals to the falls coordinators, line managers or risk specialists and reporting all cases where falls have occurred.

Page 3

7.

NHS Kirklees Falls Pathway

The Trust has in place a falls pathway which includes a Falls Risk Assessment tool which is designed to identify patients who are at risk of falls using a standardised methodology. The pathway and tool have been designed in conjunction with the many service providers including health and social care and is included as Appendix A & Appendix B. 8.

Equality Impact Assessment.

All public bodies have a statutory duty under the Race Relation (Amendment) Act 2000 to “set out arrangements to assess and consult on how their policies and functions impact on race equality.� This obligation has been increased to include equality and human rights with regard to disability age and gender.

The Trust aims to design and implement services, policies and measures that meet the diverse needs of our service, population and workforce, ensuring that none are placed at a disadvantage over others.

In order to meet these requirements, a single equality impact assessment is used to assess all its policies/guidelines and practices. This document including the pathway and tool have been found to be compliant with this philosophy and is included a Appendix D 9.

Training Needs Analysis.

A training needs analysis has been undertaken & included as Appendix C 10.

Monitoring of Compliance.

The document will be reviewed by the policy development group on a three year cycle and will be monitored on the implementation and effectiveness on an annual basis.

Annual monitoring will supported by the Risk Management Operational Group who are responsible for reviewing incidents and reports. The RMOG will provide details of the numbers of reports submitted and any actions that have taken place.

The Policy development group will make recommendations on the efficacy of the policy and advise the Governance Committee through the normal reporting mechanisms on any changes that are required.

The Governance Committee is responsible for ensuring that actions are taken as a result of these recommendations including any performance management requirements.

Page 4

11.

References

Report ‘Yorkshire Ambulance Service & Kirklees Intermediate Care falls referral pathway, Peter Horner, Intermediate Care Lead, Kirklees PCT 2007 National Service Framework for Older People (NSFOP) (DoH 2001).

Tinetti ME. Clinical Practice. Preventing Falls in Elderly Persons. New England Journal of Medicine, 2003, 348:42-49).

What is the Role of Falls? Best Practice & Research Clinical Rheumatology Vol. 19, No 6 pp913-935, 2005.)

Guideline for the Prevention of Falls in Older People, American Geriatric Society, British Geriatric Society & American Academy NICE Clinical Guideline - The Assessment & Prevention of Falls in Older People O’Loughlin J et al. Incidence of and risk factors for falls and injurious falls among community – dwelling elderly. ( American Journal of Epidemiology, 1993, 137:342-54

Stakeholders Peter Horner – Intermediate Care Team Lead Chris Bedford – Health, Safety and Security Advisor Terry Service – Assistant Director of Corporate Services and Risk.

Policy Development Group

Page 5

Appendix C

Training Needs Analysis Slips, Trips and Falls

Training will be provided for all staff regarding the management of ST&F in the workplace for clinical staff as necessary.

Who needs to attend?

How can the training be delivered?

Falls Coordinators .

Level 3 Advanced: In-depth for specific staff,

Intermediate Care Staff

Level 2

External organisations such as Occupational Health.

Delivered by qualified and competent trainers

Training as identified through PDR

Clinical Staff

Level 1 Basic Awareness

Delivered by qualified and competent trainers

Training as identified through PDR

Page 6

Responsibility for delivery of training Slips, Trips and Falls training will be provided by external trainers who are competent to deliver the training. The responsibility for identifying suitably qualified trainers is with the Head of Training.

Training needs assessment It is estimated that there are approximately 1223 staff in the organisation of which 30+ are Intermediate Care who may be called upon to provide specific advice support and guidance. The figures include including temporary and bank staff employed by the Trust who may require access to the training.

This is broken down as follows: Level 3 - Advanced

Total 2

Level 2 - Mandatory Training

Total 30

Level 1 - Basic awareness

Total 1191

The aims and objectives for the 3 levels of training are: Overall Aim: To equip staff at all levels with the information need to enable them to identify and manage incidents related to slips, trips and falls.

Objectives.

Level 1 – Basic To enable all staff to identify common hazards which could lead to slips, trips and falls how to manage them.

Level 2 – All staff To enable Intermediate Care staff to identify and manage slips, trips and falls related to staff and patient care.

Level 3 – specific identified staff To enable key staff with a specific function of providing suitable advice support and guidance to staff at all levels on the causes, impact and management actions related to slips, trips and falls in the work place.

Page 7

Equality Impact Assessment Tool

Appendix D:

To be completed and attached to any procedural document when submitted to the appropriate committee for consideration and approval.

Insert Name of Policy / Procedure Yes/No 1.

Does the policy/guidance affect one group less or more favourably than another on the basis of: • Race • Ethnic origins travellers)

2.

3.

4.

5.

6.

7.

(including

gypsies

and

Comments

No No

• Nationality

No

• Gender

No

• Culture

No

• Religion or belief

No

• Sexual orientation including lesbian, gay and bisexual people

No

• Age

No

• Disability - learning disabilities, physical disability, sensory impairment and mental health problems

No

Is there any evidence that some groups are affected differently?

If you have identified potential discrimination, are any exceptions valid, legal and/or justifiable?

Is the impact of the policy/guidance likely to be negative?

If so can the impact be avoided?

What alternatives are there to achieving the policy/guidance without the impact?

Can we reduce the impact by taking different action?

No No

No NA NA NA

If you have identified a potential discriminatory impact of this procedural document, please refer it to Director of Provider Services together with any suggestions as to the action required to avoid/reduce this impact.

For advice in respect of answering the above questions, please contact Human Resources Department Page 8