Care home risk assessment for falls: post-fall protocol and what to record

Every resident needs a falls risk assessment on admission, reviewed monthly and again after any fall. When a fall happens, staff check for injury before moving the person, start neurological observations if there is any chance of a head injury or the fall was unwitnessed, report it, and the manager reviews it for cause and learning. The record needs to show all of that happened, in order, with times, and the care plan needs to change when the review says it should.

The short answer

A care home risk assessment for falls is only useful if it leads to actions that staff actually carry out. The assessment should cover falls history, mobility, medication, continence, vision, footwear, cognition, environment and blood pressure, and every risk found should appear as a control in the care plan. After a fall, the order is fixed: do not move the person until you have checked for injury, call 999 where the injury could be serious, start neuro observations for any head injury or unwitnessed fall, record what happened, tell the people who need to know, and review the fall for a root cause. Report to CQC when the fall causes serious injury or death. Then look at the pattern across the month, not just the single event.

Why falls are the incident inspectors read first

Falls are the most common incident in most care homes, and they are the incidents an inspector opens first. A fall record tells them how fast staff responded, whether staff knew the protocol, whether the manager looked at it afterwards, and whether anything changed as a result. Three falls in a month for the same person with the same care plan is a finding waiting to be written up.

Falls also carry the biggest consequences. A hip fracture in an older resident changes the rest of their life. A head injury in someone on an anticoagulant can be fatal within hours. And a fall that nobody saw raises questions about staffing and supervision that you will be asked to answer. Treating falls as routine paperwork is the single most common way a home that is otherwise doing well ends up with a Regulation 12 breach.

At a glance: falls in care homes

This table sets out the stages of falls management and the record that should exist for each one.

Who needs a falls risk assessment and when

Everyone. It is tempting to skip the assessment for a mobile young adult in a learning disability service or a resident in a mental health home who walks to the shops every day. Do not. The assessment for those people may be short and may conclude that the risk is low, but that conclusion needs to be written down, dated and signed, because the day that person falls the first question will be what you knew about their risk.

Complete the assessment within 24 hours of admission using the information you have, and mark it as provisional if you are still waiting on history from the previous placement or the hospital. Review it at least monthly, immediately after any fall, and after any change in health, medication, mobility or mental state. A chest infection, a new antipsychotic, a period of low mood or a change of room are all triggers.

Keep every version. A risk assessment in care homes that only shows the current state hides the history, and history is exactly what a coroner or an inspector will want to see. A universal scored assessment with version history handles this automatically; see care records.

Care home risk assessment for falls: what to include

There is no single mandated falls tool for care homes in England. NICE guidance is clear that a multifactorial assessment matters more than a numerical score, and that scores on their own do not predict falls well. What matters is that you look at the right factors, record them consistently, and turn each one into an action.

Person factors

• History of falls in the last twelve months, including near misses and falls in hospital.
• Mobility and transfers, the aids the person uses and whether they use them correctly.
• Continence and urgency, because hurrying to the toilet at night is one of the most common causes.
• Vision, hearing and footwear, including slippers that have lost their grip.
• Cognition, mood and behaviour, including impulsivity and whether the person will call for help.
• Postural hypotension, with lying and standing blood pressure where dizziness is reported.
• Bone health, because osteoporosis changes what a fall does to the person.

Medication and environment

• Medication, especially sedatives, antipsychotics, antihypertensives, opioids, diuretics and anything started or changed in the last month.
• Environment: lighting, flooring, bed height, clutter, thresholds and where the call bell is.
• Equipment: sensor mats, low beds, crash mats, grab rails and whether they are in working order.

Risk assessment examples: turning a score into actions

Managers often ask for risk assessment examples, and the useful ones show the link between a finding and a control. A score with no action is just a number. Here is the shape of a good entry for a resident in a nursing home.

Finding: two falls at night in the last month, both on the way to the toilet, both after 2am. Contributing factors: new diuretic started three weeks ago, bedroom light switch is across the room, resident will not use the call bell because she does not want to bother staff. Actions: GP asked to review timing of the diuretic; night light installed and switched on at bedtime; commode placed by the bed with the resident's agreement; hourly checks between midnight and 6am for two weeks; review in 14 days.

Compare that with an entry that says high risk, sensor mat in place, monitor. The second version tells nobody what the actual risk is, and it could be copied to any resident in the building. If your assessment reads like that, an inspector will assume the care plan was not built around the person. See risk assessment examples and templates for social care for more worked examples.

Positive risk taking and the right to fall

Positive risk taking is a phrase that appears in a lot of care plans and is understood in very few. It means the person's own choices carry weight, that avoiding all risk is itself harmful, and that the home has a duty to support the life the person wants rather than the safest possible version of it.

In practice, a resident with capacity can decline a sensor mat, refuse a walking frame, or insist on going out alone. The care plan needs to record the conversation: what risks were explained, what alternatives were offered, what the person decided and why. Then the home does what it reasonably can to reduce the remaining risk without overriding the decision. That might mean a better pair of shoes, a mobile phone with the home's number saved, or a check-in time.

Where the person lacks capacity for the specific decision, the Mental Capacity Act applies. Make a best interests decision with the people who know them, record it properly, and remember that some falls controls, bed rails and locked doors in particular, are restrictions that need their own assessment and may need a DoLS application.

Learning disability and mental health services: what changes

In an older people's home most falls come from frailty. In a learning disability or mental health home the causes are different, and a risk assessment in care that was written for a nursing home will miss them. Common causes in these services include seizures, side effects of antipsychotics and mood stabilisers, alcohol and substance use, impulsivity, sensory processing differences, distress behaviour and physical health conditions that have not been picked up because the person cannot describe symptoms.

The process is the same but the questions are different. Ask whether the person has an epilepsy care plan and whether seizures are being recorded. Ask whether a recent medication change has caused drowsiness. Ask whether the person understands why a control is in place and whether they will accept it. Ask about footwear, because trainers with worn soles are a frequent finding.

The record also needs to fit the person. Some residents can tell you exactly what happened. Others cannot, and an unwitnessed fall in a person who cannot describe pain needs a lower threshold for medical review than the same fall in someone who can.

Medication and falls

Medication is the factor managers most often underestimate and the one that is easiest to change. Sedatives, antipsychotics, antidepressants, antihypertensives, diuretics, opioids and anything that causes drowsiness or dizziness all raise risk. The risk is highest in the two weeks after a new medicine is started or a dose is changed.

Build a link between the medication record and the falls assessment. When a medicine in one of those groups is started, changed or stopped, the falls risk should be reviewed within a week. When a fall happens, the reviewing manager should look at the MAR chart for the previous month and note any change. If your eMAR flags new prescriptions, use that as the prompt.

Ask the GP or pharmacist for a structured medication review for anyone who has fallen twice in six months. That request, and the outcome, belongs in the care plan. Inspectors regularly find repeat fallers on a sedating medicine that nobody has questioned for years.

Environment and equipment

Walk the building at night. Lighting that looks fine at 3pm can leave a corridor in shadow at 3am. Check bedroom light switches, the route to the toilet, floor surfaces, thresholds between rooms, loose rugs, trailing cables and where residents put their walking aids at bedtime.

Equipment helps only when it matches the cause. A sensor mat gives staff a warning that someone is up, which is useful if staff can reach them in time and useless if they cannot. A low bed with a crash mat reduces the consequence of rolling out of bed but does nothing for a fall on the way to the toilet. Bed rails can prevent a roll but create an entrapment risk and can turn a low fall into a high one when a person climbs over them. Every piece of equipment should have a reason recorded, a check that it is working, and a review of whether it made any difference.

Equipment maintenance is a nursing home risk assessment finding in its own right: an untested sensor mat or a hoist past its service date will be picked up.

Night-time falls

A large share of falls happen between 10pm and 6am, and most of those involve the toilet. If your monthly analysis shows this pattern, the answers are usually a combination of continence planning, lighting, timing of diuretics, the position of commodes and the frequency of night checks.

Night staffing also matters. A home that runs with two waking staff for forty residents may find that a sensor mat alarm cannot be answered fast enough. If the analysis says that, the honest response is to look at deployment rather than add more alarms. Record the reasoning either way, because staffing decisions with a rationale are defensible and staffing decisions without one are not.

Night staff need the same training as day staff. Falls at night are more often unwitnessed, so the neuro observation rule is triggered more often.

The post-fall protocol in order

Staff should be able to say these steps from memory. Put a laminated copy in the office and on the medication trolley, and test it at supervision.

1. Do not move the person. Check responsiveness, breathing, pain, obvious injury, deformity and bleeding. Ask what happened if they can tell you. Keep them warm and reassured.
2. Call 999 if the person is unresponsive, has a suspected fracture, hip or spinal pain, heavy bleeding, is on anticoagulants and hit their head, or if you are not sure. Do not lift anyone with a suspected hip or spinal injury.
3. Head injury or unwitnessed fall: start neurological observations and follow your home's schedule. Escalate any change.
4. Move safely. If there is no injury and the person can get up, use the taught technique or the lifting equipment your home has. Never lift under the arms.
5. Complete a body map and record vital signs even where there is no visible injury.
6. Record the incident on the same shift with times, location, what the person was doing, what staff found and what they did.
7. Inform the manager, the GP where there is any injury or change, and the family or advocate.
8. Increase observation for the next 24 to 72 hours and record it.
9. Refer to the falls service, physiotherapy or occupational therapy where indicated.
10. Review the risk assessment and care plan within 72 hours and record what changed.

When to call 999

The mistake homes make is not calling too rarely but calling inconsistently. One senior calls for every fall; another never does. Neither is right. The decision rests on what you find when you check the person, and the criteria should be written down so that any member of staff reaches the same answer.

Call an ambulance for unresponsiveness or reduced consciousness, a suspected fracture, particularly hip pain or a leg that looks shortened or rotated, any neck or back pain, heavy bleeding, a head injury in someone on an anticoagulant or antiplatelet, a seizure, chest pain or breathing difficulty, or any deterioration during observations. Also call if the person cannot get up and you have no safe means of lifting them.

If none of those apply, contact the GP or NHS 111 the same day for any injury, pain or change from normal. Record the call, the time, who you spoke to and what they advised. If you decide not to seek medical advice, write down why.

Head injuries and neurological observations

Any fall where the person hit their head, might have hit their head, or where nobody saw the fall, triggers neurological observations. The point is to catch a slow bleed before it becomes fatal, and the window is measured in hours, so the observations have to start immediately, not after the incident form is finished.

Your home's schedule should be written in your policy and should follow the pattern in NICE head injury guidance: frequent observations in the first two hours, then spacing out over the following 24 hours if stable. Record level of consciousness, pupil size and reaction, limb movement, pulse, blood pressure, breathing and temperature on a dedicated chart, with a time and a signature for each set.

Escalate immediately for any drop in consciousness, new confusion, vomiting, severe or worsening headache, unequal pupils, weakness on one side, a seizure, or clear fluid from the nose or ears. If the person is on an anticoagulant, they go to hospital regardless of how well they look. Night staff should be competent in this, because most unwitnessed falls happen at night.

Moving someone after a fall

Once you are satisfied there is no injury that prevents movement, help the person up using the method your home has trained. Many homes use a lifting cushion or hoist; some teach a backward chaining technique where the person gets themselves up with guidance. Whichever it is, staff need to have been trained in it and the record should say which was used.

Never lift someone under the arms and never drag. If the person cannot get up with the equipment available, they stay where they are, kept warm and comfortable, until the ambulance arrives. A long lie on the floor is harmful, so if your home has no lifting equipment and a resident cannot get up, that is a gap to fix rather than a reason to lift manually.

What the record needs to say

The incident record is the document that will be read most closely afterwards. Write it on the same shift, in the first person where possible, and cover the facts before the opinions.

• Date, time and exact location.
• Whether the fall was witnessed and by whom.
• What the person was doing immediately before, and what they say happened.
• What staff found: position, responsiveness, pain, visible injury, vital signs.
• What staff did, in order, with times: checks, 999 call, observations started, method of moving.
• Who was informed and when: manager, GP, family, advocate.
• Footwear, lighting, equipment in use and whether it was working.
• Medication changes in the previous month.

Avoid words like found on floor with nothing else. That phrase tells the reader that nobody knows what happened and nobody asked. If the fall was unwitnessed, say so, say what the person and any nearby residents reported, and say what the staff member concluded from the position and surroundings. The daily log entry for that shift should match the incident form on times and facts.

Body maps and injury records

Every fall gets a body map, including falls with no visible injury, because bruising often appears the next day and the map proves there was nothing at the time. Mark each injury with size, colour, type and location, and date and sign it. Repeat the map at 24 and 48 hours where there was any impact.

Body maps are also safeguarding evidence. An injury that does not fit the reported fall, or bruising in a pattern that suggests a grip, needs to be raised as a safeguarding concern rather than filed. Managers should look at every body map from the last month during the monthly review and check the injuries make sense against the incidents.

Keep the body map with the incident, not in a separate folder, so the fall, the map, the observations and the review are in one place.

Reporting: who needs to know

Every fall is reported to the manager or the person in charge on that shift, and the manager decides on onward reporting. The GP is contacted for any injury, any pain, any change in condition and any fall in a person on anticoagulants. The family or advocate is told the same day unless the person with capacity has asked otherwise, and the conversation is recorded.

Where the fall caused harm, the duty of candour applies. That means telling the person and their representative what happened, apologising, explaining what you are doing about it and confirming it in writing. Keep a copy of the letter with the incident.

If the fall involved another resident, a staff member's action or inaction, faulty equipment or a possible failure of care, a safeguarding referral to the local authority may be needed alongside any CQC notification. Your incident reporting process should prompt each of these decisions so nothing depends on memory.

Report to CQC: when a fall is notifiable

Not every fall is notified. You must report to CQC when a fall results in serious injury or death. Serious injury for this purpose includes a fracture, a head injury needing hospital treatment, an injury that leads to a long-term change in health or function, and any injury that requires treatment to prevent death or serious harm. A fall that leads to a hospital admission will usually meet the threshold; a bruise treated in the home usually will not.

Deaths are notified regardless of cause, so a resident who dies after a fall, even weeks later and even from another cause, is notified as a death. Where the fall involved abuse or neglect, it is notified as an abuse or allegation of abuse notification as well as a serious injury.

Submit the notification without delay, which in practice means the same or the next working day, and keep the reference number with the incident record. A late or missing notification is a breach in itself, separate from whatever happened. See CQC notifications: what to report and when for the full list.

Safeguarding and unwitnessed falls

An unwitnessed fall is not automatically a safeguarding matter, but it should always prompt the question. Ask whether the person was left alone longer than their care plan allows, whether the call bell was reachable, whether a sensor mat was switched off, whether staffing was below the planned level, and whether the injury fits the account.

If any of those answers point to a failure of care, raise a safeguarding concern with the local authority, tell CQC, and start your own investigation. If the answers are all satisfactory, record that you asked the questions and what you found. That record protects the home when the question comes up later.

Several unwitnessed falls on the same shift pattern, or in one part of the building, are a governance issue even if each looked innocent on its own.

Reviewing each fall for a root cause

The manager or deputy reviews every fall within 72 hours. The purpose is not to blame but to understand why it happened and what would have made it less likely. Ask why at least three times. The resident fell on the way to the toilet. Why was she going alone? Because she did not use the call bell. Why not? Because she thinks staff are too busy at night. Why does she think that? Because on two occasions nobody came for ten minutes. Now you have something you can change.

Record the contributing factors under headings: person, medication, environment, equipment, staffing and communication. Then record actions with an owner and a date, and mark whether the risk assessment and care plan were updated. An incident review that captures root cause and flags whether the event is CQC notifiable makes this routine; see CQC compliance.

Close the loop. At the next review, check whether the actions were done and whether they worked. An action that was written and never done is worse than no action, because it shows the home knew and did nothing.

Post-fall review of the care plan

After every fall the risk assessment is repeated and the care plan is checked against the findings of the review. The update should be specific. Increase night checks to hourly until 30 November and review. Ask GP to review dose of mirtazapine. Replace slippers with fitted shoes. Move bed to allow access from the left side. Each of those can be checked by anyone reading the plan.

Involve the person. Ask them what they think caused the fall and what would help. In learning disability services, involve the family or advocate and use accessible formats where they help. A person who has agreed to a control is far more likely to accept it than one who has had it imposed.

Date the new version and keep the old one. When you have three versions across three months, the story of what you tried and what worked is visible without anyone having to reconstruct it.

Monthly falls analysis

Once a month, list every fall by resident, date, time, location, whether witnessed, injury, cause and action. Then look for patterns. Common ones are a single resident accounting for most falls, a cluster between certain hours, a particular corridor or bathroom, a spike after a medication change, or an increase when agency staff are on shift.

Write a short analysis: what the numbers show, what you think is behind it and what you are changing. Share it at the staff meeting and keep it in your governance file. This is the single document that most convincingly shows an inspector that the home learns from incidents.

A rise in falls is not automatically a failure, particularly if admissions have changed, but a rise with no explanation and no response is.

Referrals: GP, falls service, physiotherapy and occupational therapy

A fall is a signal that something has changed. Two falls in six months, or one fall with injury, should prompt a referral for a multifactorial assessment through the GP or the local falls service. Ask specifically for a medication review, a check for postural hypotension, a vision check and a bone health assessment.

Physiotherapy can improve strength and balance and advise on the right walking aid. Occupational therapy can assess the room and recommend equipment. In learning disability and mental health services, ask the community team to consider whether a physical health cause has been missed, because pain, infection and constipation all present as falls in people who cannot say what is wrong.

Record each referral with the date sent and the outcome. A referral made and never chased is a common finding.

Training and competence

Every member of staff, including night staff, agency staff and new starters, needs to know the post-fall protocol before they work unsupervised. Include it in induction, check it at supervision and run a scenario at a staff meeting at least once a year. Ask a staff member to talk you through what they would do if they found a resident on the floor at 4am. If they hesitate on the head injury rule or the 999 criteria, that is your training need.

Neurological observations need specific competence. Staff should be signed off as able to complete the chart and to recognise the signs that need escalation. Moving and handling training should cover the technique and equipment your home actually uses for getting someone up from the floor.

Keep the training record where you can produce it. An inspector who reads a fall record and then asks whether the staff member on shift had been trained will expect an answer within a minute. HR and training records that link to the staff member make that simple.

Using an incident reporting system to keep it tight

None of this depends on software, but a good incident reporting system makes the process harder to skip. It should prompt the staff member for the facts in order, attach the body map and observations, alert the manager immediately, hold the review with root cause and actions, flag whether the event is notifiable, and produce the monthly analysis without anyone re-typing anything.

Kiwi does this with an incident review that records root cause, links the fall to the resident's risk assessment and care plan, and carries a CQC-notifiable flag so the decision is made and recorded every time. The falls analysis is a report rather than a spreadsheet you build at the end of the month. If you want to see how that fits your home, book a demo.

Whatever system you use, pick a fall from last month and follow it from the incident form to the review to the care plan change to the monthly analysis. Where the trail breaks is where your process needs work.

Common mistakes

• A falls risk assessment that produces a score but no actions, or actions so generic they could apply to anyone.
• Staff moving the person before checking for injury, particularly lifting under the arms.
• Neurological observations not started because nobody saw the person hit their head.
• Incident records that say found on floor with no account of what happened or what was done.
• No body map because there was no visible injury at the time.
• The risk assessment and care plan not updated after the fall, so the same fall happens again.
• Serious injury not notified to CQC because the manager assumed a fracture in a frail person was not serious.
• Falls counted every month but never analysed, so the pattern is never seen.

What good looks like on inspection day

An inspector will ask for the incident log and pick two or three falls. For each one they will want the incident form, the body map, the observation chart if there was a head injury, the review with root cause and actions, the updated risk assessment and care plan, and evidence that the family and GP were told. They will check the times add up and that the review happened within days, not weeks.

They will then ask a staff member what they would do if they found a resident on the floor, and compare the answer to your policy. They will ask you what the falls trend looks like and what you have changed because of it. Have the monthly analysis to hand and be ready to talk about a specific resident whose falls reduced after a change you made.

Finally, they will check notifications. Any fall with a fracture or hospital admission in the last year should have a notification reference next to it. If your records are digital, be ready to open them on screen and show the trail in a couple of minutes; inspectors notice when a home can do that without hunting.

Final conclusion

Falls are the incident that most reliably shows whether a home is safe and well-led. The process is not complicated: assess everyone, act on what the assessment finds, respond to each fall in the right order, record it properly, review it for cause, change the plan and look at the pattern every month. What makes the difference is doing every step every time, and being able to show the trail from the fall to the change it produced. Do that, and falls become evidence of good care rather than evidence against it.

Frequently asked

Do I need to call 999 for every fall in a care home?

No. Call 999 when the person is unresponsive, has a suspected fracture, hip or spinal pain, heavy bleeding, a head injury while on anticoagulants, or whenever you are unsure. For every other fall, check for injury before moving, complete observations and contact the GP if there is any injury or change from the person's normal.

How often should a falls risk assessment be reviewed?

Complete it on admission, review it at least monthly, and repeat it after every fall and after any change in health, medication or mobility. Keep each version so the trend over time is visible to you and to an inspector.

When must a fall be reported to CQC?

A fall must be notified when it results in serious injury such as a fracture, a head injury needing hospital treatment, or death. Falls that involve neglect or abuse are also notified as safeguarding matters. Every other fall is recorded and reviewed internally but not notified.

What are neurological observations after a fall?

They are a set of checks for signs of brain injury: level of consciousness, pupil size and reaction, limb movement, pulse, blood pressure and breathing. Start them whenever a person hit their head, might have hit their head, or the fall was unwitnessed. Follow your home's schedule and escalate any deterioration straight away.

Can a resident refuse a sensor mat or bed rails?

Yes, if they have capacity to make that decision. Record the discussion, the risks explained and their choice in the care plan as positive risk taking. If they lack capacity, make a best interests decision with the people who know them, and remember bed rails can be a restriction that needs its own assessment.

What is a good falls risk assessment example for a learning disability service?

A good one looks at the person, not just age. It covers seizures, medication side effects, impulsivity, sensory needs, footwear, alcohol where relevant and whether the person will ask for help. Every risk identified turns into a specific action in the support plan.

Should I use a sensor mat for every resident who has fallen?

No. A sensor mat is one option and it only helps if staff can respond fast enough to matter. Choose the control that fits the cause of the fall, and review whether it actually made a difference at the next review.

Sources

• NICE CG161 Falls in older people: assessing risk and prevention
• NICE CG176 Head injury: assessment and early management
• NICE Quality Standard QS86 Falls in older people
• CQC: Statutory notifications guidance for providers
• Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 Safe care and treatment
• Care Act 2014 statutory guidance, Chapter 14 Safeguarding
• Public Health England: Falls and fracture consensus statement