Health and Social Care Committee

Inquiry into residential care for older people

RC35 – Cardiff and Vale University Health Board (UHB) Falls and Bone Health Programme (F&BHP)

National Assembly for Wales’ Health and Social Care Committee

Inquiry into Residential Care for Older People

Role of responder

This response is from the Cardiff and Vale University Health Board (UHB) Falls and Bone Health Programme (F&BHP), which sits under the Cardiff and Vale Integrated Health and Social Care Programme. A working group comprising of members from statutory, the Third and independent sectors advises the F&BHP.

The F&BHP has made contacts with care providers through individual meetings and at two seminars to ask their needs and requirements for falls prevention and management. A major concern of the independent sector is the variable level of communication from the NHS. The UHB is committed to working in partnership.

Background Information - Falls and Bone Health

Although not an inevitable part of ageing, nevertheless the risk of injurious falls increases with age and frailty. The changing demographic picture is an imperative driver to reduce harm from falls and minimise risks. Currently falls and fractures are estimated to cost Cardiff health and social care £10-12 million a year (with hip fractures the greater part). The human cost of falls and fractures is immense with loss of confidence and independence, which may result in social isolation, depression and admission to residential care.

Falls prevention is a complex issue and all ambulant residents are at a high risk of falls in care and other institutional settings. The frequently quoted figure for risks in care settings is 1.5 falls per bed per year. Amongst the challenges that the UHB faces, for example balancing risks with the importance of promoting an autonomous life for a resident/patient, are well understood by the care provider sector.

Entering residential care

Falls are a common factor in the decision for people to enter care homes. People who have fallen benefit from multifactorial assessment, in many cases this reduces the risks or frequency of future falls. Where falls are a feature contributing to a decision to enter a care home the relocation itself may not reduce the risk of falling.

UHB discharges many patients to the residential care sector who have fallen (this includes following a falls related admission from the community; following a fall in residential care or an in-patient fall). It is important that partnership working and a standardised approach to falls and bone health is promoted across the sectors, as the sectors are interdependent on one another. A whole systems approach is crucial to improve the patient experience.

Community based services

In November 2011, the UHB launched two new falls and bone health pathways (aligned to the 1000 Lives+ "Reducing harm from a fall” programme). An older person attending Unscheduled Care with a fall from the community or care setting who is not admitted is screened for an on-going falls risk. Primary Care is informed of the result and undertakes further assessment, interventions and referrals. It is expected that through the interventions the risk of another fall is reduced and independence promoted. The pathway includes a home safety checker leaflet by Care and Repair. This gives useful community based information for home adaptations and other services to ensure that a person can remain for as long as possible in their own home.

The Cardiff and Vale Community Resource Teams (CRTs) in Phase 2 (from Spring 2012) will support reablement and admission avoidance (from acute care and residential care). The fore-runner of the CRTs (models such as Penarth Integrated Care Team or Cardiff East Locality Team have demonstrated admission avoidance and appropriate step-up and step-down provision.

Experiences of service users

The UHB has not undertaken consultation with service users of residential care relating to falls and bone health, but extensive consultation was undertaken with community dwelling older people to:

· Set the direction and develop the outcomes for the Falls and Bone Health Programme

· Explore information needs and develop two leaflets (in-patients and a home safety checker).

Quality of services

Falls risk assessments and care plans

There is a statutory requirement for care providers to undertake a falls risk assessments, and a requirement to record and register all falls. Many care providers use a modified “Stratify” tool – however studies have shown this tool performs poorly and its use is no longer supported by its author. Best evidence suggesting a care planning approach. There is a tension between what are CSSIW regulatory requirements in terms of assessment and evidenced-based practice. Routine risk assessments for bone health are not undertaken, although a question on osteoporosis is asked.

Falls registers in current use

The maintenance of a falls register is a requirement for all care home operators. However, various forms of registers are kept and monitoring of trends is not a routine; not all systems are easily auditable. CSSIW Inspectors ask different responses following a fall. Some homes report all falls via a Regulation 38 document, while others only report falls requiring hospital treatment. Domiciliary care providers use a Regulation 26 document for serious injury.

Beds and equipment are an issue for care providers, for example beds in care homes are often of a normal divan type without the facility to become ultra low for a person likely to fall. The availability of ultra low beds in nursing homes is variable and so are hip protectors.

Training

The Care Provider sector (nursing, residential and domiciliary) was consulted during the development of the UHB’s “Falls prevention and management procedures”. The sector was invited to the launch in April 2011 and copies of the document with useful appendices were sent to each provider. The UHB with Cardiff and the Vale of Glamorgan’s Social Care Workforce Development Co-ordinators held a successfully evaluated seminar in November 2010, providing joint training for health and social care staff. A further seminar is planned for February 2012 with training based on the Royal College of Physicians “National Audit of Falls and Bone Health Audit” (This audit whilst focussed on health service providers includes returns from operators of a numbers of residential care settings). The seminar will provide training guided by the AuditRecommendations and include such issues as when to call primary care following a fall and post falls investigations.

It is worth noting that carers undertaking Qualification Credit Framework (QCF) Diplomas training receive information about risks from a health and safety perspective but not about intrinsic risks for an individual, for example dementia.

New and emerging models of care provision

The RCP Audit Recommendations ask that care homes have:

· Accurate data and information for service planning

· Medication reviews for all residents

· Access to exercise

· Provision of training

Recommendations

1.   That the complex issues of falls prevention and management and bone health protection require a co-ordinated approach with health working in partnership with the care provider sector. This might include:

· improving communication between the sectors

· sharing  documentation with care providers

· joint learning/training experiences

2.     That the RCP Recommendations are implemented through:

· promoting the use of easily auditable falls registers by the care providers

· promoting and supporting a standardised approach to falls prevention

· improving accurate data and information about falls

· ensuring systems are in place for regular medication reviews

· availability of therapeutic exercise

· a focus on admission avoidance following a fall in both the community and in a home

· training events on  falls prevention; post falls management and bone health protection issues

· reviewing of local authority and health contracts

Amanda Ryan, Falls and Bone Health Programme Manager,

Denise Shanahan, Consultant Nurse Older Vulnerable Adults,

Cardiff and Vale University Health Board

December 2011