1. Falls in Older Adults I/P units
Team presentation: Avon and Wiltshire Mental Health Partnership Trust

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Welcome
We are a mental health trust with 8 later life wards, one closed last June.
Our falls are variable but we have a population that are at least three times as likely to fall as those without cognition issues. Our service users are admitted to unfamiliar environments with late stages of dementia or acutely unwell with their MH. We use medications that are high risk for falls and many have physical health needs as well.
We have been working on reducing falls for the last few years and they have been slowly reducing or staying steady and so recently moved our focus to frequent fallers as they make up a majority of fall numbers.
All admissions have a MFRA completed that relates to their care plan and we review the falls on wards regularly
Regular review has identified medications as an issue and we are working on increasing the time between falls in the frequent fallers

3. Situation
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Our aim is to reduce the number of falls across later life wards
Sign up to safety priority
Reduce falls by 50% (Very ambitious)
Reducing falls that result in harm and increasing the time between frequent falls are additional outcome meaasures

4. Background Main title slide page Key Elements :
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Key Elements :
Raising awareness of falls
Improving the incident form completion
Developing the MFRA to be added to electronic system
Adding the post falls checklist
PDSA cycles initially on falls training, falls leaflet, communication chart, review group. None more recently but still use process

5. Driver Diagram

6. Data – Total Number of Falls
Main title slide page
Data – Total Number of Falls
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7. Data – Falls SI’s

8. Assessment
The greatest improvement has come from continued focussing on falls awareness and their management
Identification of frequent fallers and focussing on increasing the time between falls rather than reducing the number .
An improvement has come in some areas from a MDT approach and review of medications.
Our biggest challenges are changes in staffing with staff not knowing patients

9. Recommendation
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Working on having a weekly review of falls as a team and what method of doing this works best – testing currently across teams
Recommendations are to keep on going ! Needs regular updates and training .
Standardisation of medication reviews as we use high risk medication in our population
Being aware of comorbidities.

10. Thank you for listening
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Thank you for listening
Welcome
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