Background Falls guidelines were updated for the hospice in 2022 with risk assessment currently based on the Morse Falls Scale and NICE quality standards on falls. New Assessment frameworks were also created to ensure compliance with the guidelines. There was concern that the guidelines were not always being adhered to and management post falls and risk assessment could be optimised.

Aims To assess compliance with hospice standards and to improve patient safety. Introduction of PSIRF process replacing Serious Untoward Incidents prompted review of our falls prevention and management.

Methods Falls in a 4 month period on the inpatient unit were reviewed. A list of all falls in the 3 month period of September to December 2023 were generated through the Vantage incident reporting system. Patients who fell were analysed for assessment prior to fall and management after the fall.

Results Our results showed 34 falls in this time period from 18 patients. On admission 12 of these patients were deemed high risk, however, only 50% of these patients had a plan to reduce falls.

Hospice local guidelines suggest that those who have more than two falls be referred to the Falls Champion - of which there were four patients having more than three falls, none of whom were referred to the Falls Champion.

Outcome Immediately introduced mandatory referral to the Physiotherapist at the inpatient MDT following two or more falls to replace the Falls Champion. The introduction of SystmOne in June 2024 has allowed us to implement national Falls Risk Assessment tool. Increased physio/OT support for inpatient unit patients.

Conclusions Over the next 6 months we plan to revaluate falls equipment for Inpatient services as well as commence training sessions for all clinical hospice staff on falls prevention. We will also restart the Bedside Mobility Assessment tool training to support Inpatient services staff to carry out a safe mobility assessment and guide them on appropriate actions.