Exploring the organisation and delivery of falls management in care homes for older people in England | BMC Geriatrics

The results were structured with four levels of organisational context: (1) Health and Social Care System; (2) Care home system; (3) Care home team and (4) Individuals. A summary of each of these levels will now be presented.

Health and social care level determinants

Contextual factors at the wider health and social care level were mapped to six of the CFIR constructs and these are summarised in Table 3.

Integrating a disjointed system

There was a recurrent theme that more work was required to break down traditional silos between sectors involved in falls management. Health leaders reported that approaches to address silo working, such as greater care home representation on system wide falls in care homes groups, were a work in progress. NHS staff and care home managers were frustrated at the speed of change. Challenges regarding who should pay for falls management approaches and the different funding mechanisms were identified. Separate record systems created challenges for sharing information about falls across organisations. This added to the time demands on staff and external MDT members due to duplication of documentation.

‘I think NHS and [name of Local Authority] are already disjointed so to then get us into a disjointed system is difficult, but they do try their best.’ (Interview with care home manager).

Proactive versus inevitability

There was tension between being proactive to prevent a fall and the perception that some falls are inevitable. Clinical leads felt that this acceptance of falls sometimes led to reduced reporting of problems contributing to falls, such as agitation. Commissioners advocated for a proactive approach in line with national policy drivers but also suggested that culture change was required for care home to see themselves as ‘a key player in the more proactive agenda.’ (Interview with commissioner)

‘if a resident’s about to fall, that you can’t actually stop it anyway. You can do the prevention, you can do the tasks like the cleaning up and things like that, but when it actually does come to a fall, it is mostly purely accident, and you can’t actually stop that.’ (Interview with carer).

Financial pressures

Stretched finances across the health and social care system made consistent approaches to falls management difficult. Decisions by health commissioners about whether to fund falls management appeared variable. Some care homes had access to a specialist falls teams whereas others did not, and waiting times were variable. Provision of falls training in care homes by an NHS organisation had been decommissioned due to cost. Pilots needed to demonstrate impact in order to be rolled out across the system, but this was difficult to evidence due to the heterogeneity of care home providers.

‘resource and funding, anything that is done needs to be rolled out consistently across large number of care homes in the area which costs a lot of money. This is a challenge with the current financial pressures and the need to evidence benefit and good value for money’ (Interview with commissioner (recoding and researcher notes).

‘Historically when there was a specialist falls service rather than kind of a general service that also saw fallers, there was a health promotion specialist that provided training into care homes, although that was effectively decommissioned, because it’s quite an expensive thing to do’ (Interview with falls lead involved in the organisation of falls).

Variation in support available

Services available to support falls management differed across care homes. For example, homes in one county had access to a specialist falls team whereas homes in another county did not. There was confusion about referral pathways and some cares homes experienced delays in receiving support from external services. Negative preconceptions about care homes amongst healthcare professionals were thought to impact on recruitment to care home support roles and service provision. Health professionals reported these roles were less attractive for some due to fear, a lack of interest and the complex needs of care home residents.

Relationships across the system

Weekly ward rounds and a consistent, named health professional linked to the care home supported care homes with accessing wider support to manage complex needs of residents. Relationships between care home staff and wider teams and system partners were crucial as external professionals relied on staff’s knowledge of residents for decision-making. However, issues arose when care home staff and health professionals felt their perspectives had been overlooked when working together, causing frustration.

‘There is one GP practice that comes to the care home and usually they have the same GP. Nurse thinks this is helpful, multiple GPs make things hard because the residents are so complex’’. (Observation field note)

Complexity of resident’s needs

Care home staff worked with residents who had complex needs. Managing falls was also difficult as it involved considering a wide range of risk factors and possible actions. Challenges with managing the impact of multiple falls risks and health needs of individuals were observed, particularly for residents with dementia. Staff also had to consider the safety of others, including other residents and staff, when making decisions about falls. The high level of support needed by care homes, including general reviews, hospital discharge assessments, problem-specific reviews and equipment support, led to challenges with fitting all requests into weekly rounds.

Care home organisation

Contextual factors at the care home organisational level were mapped to five of the CFIR constructs and these are summarised in Table 4.

Environment

The design of some care homes was problematic for falls management, with trade-offs between privacy, supervision and activity promotion. While more secluded areas may be more difficult to supervise, staff reported that open communal areas created challenges for ensuring privacy when a fall occurred. Environmental risk factors were important to both residents and care staff. Noise levels, interruptions and space constraints affected communication in meetings where falls were discussed. Some care homes had limited digital infrastructure which restricted the accessibility of virtual or hybrid meetings. Meetings were observed to be virtual, hybrid and in person.

‘A lot of the residents can’t get through them doors because they’re too heavy. We’ve got one that likes to go her room early, but someone has to take her because she’s going through a fire door so she’s not independent.’  (Interview with resident).

Safety culture

Safety was at the heart of decision-making about falls by care home staff. Balancing safety risks against promotion of independence was complex and staff had different views about how best to manage these situations. Criticism by external organisations was perceived to lead to risk aversion and mistrust between those involved.

‘First thing is safety then you can encourage independence’.

(Interview with care home clinical lead- researcher notes)

‘I think care homes as well are really – have been criticised a lot – and kind of perhaps a little bit risk averse if they’ve been shouted at once by an ambulance for the fact of getting somebody off the floor when they should have done’ (Interview with falls lead involved in the organisation of falls.

Competing priorities

Falls management had to be balanced with other responsibilities and included many different approaches which created difficulties for prioritisation. Some care homes more overtly prioritised falls discussions in their meetings than others, for instance including falls as a standing agenda item. Implementation of falls management approaches was influenced by the time and cost commitment required by the care home and individuals delivering or receiving the interventions.

‘So who is high risk of falls? We will make a group and put them inside the lounge and then one of the staff can stand in the lounge and closely monitor for falls. So not always the four staff can stay on the floor, sometimes staff need to help with toileting and pad changing so one staff will stay in the lounge with those at risk of falls and the other staff will help the other residents.’ (Interview with carer).

Analysis and learning approaches vary

Care homes developed their own approaches to analysis and learning from falls. Ownership of the care home influenced the manager’s autonomy to try new approaches, with individually owned homes having greater flexibility. Falls analysis was led by care home management teams with top-down oversight and variable input from staff who worked on the floor.

‘up until recently, it was not easy to make changes at an individual care home level. Manager thinks this will improve as the regional manager has just started monthly meetings between managers across the region. This is a forum to share ideas and best practice.‘.

Observation field note)

‘I think as a medium sized care home but a single care home, we do have that ability to be flexible and dynamic in the way we are talking to people, we can suddenly have meetings if we want to and we don’t have to go to head office if we want to buy any equipment or stuff like that.’ (Interview with care home manager).

Workforce challenges

Workforce challenges were problematic for implementing falls management approaches and engaging with quality improvement work, including staffing levels, turnover and skill mix. Pay and COVID-19 were thought to have exacerbated workforce challenges. Staff became more task-focused and agency workers with less knowledge of residents were used when staffing resource was limited. Providing supervision and promoting activity were noted as particularly difficult with a limited workforce.

‘The 1–1 is only in place between 1 and 9 o’clock due to agitation levels and so we need to support around those time. The 1–1 is done by an agency staff who watches all the time to prevent falls. Difficulty doing that outside those times.’ (Interview with carer- researcher notes).

Care home team

Contextual factors at the care home team level were mapped to four of the CFIR constructs and these are summarised in Table 5.

Formal and informal communication

Care homes used daily handovers as the main structure to formally communicate information about falls. Some homes had additional structures in place such as team meetings with senior carers and management teams, which included more in-depth falls discussions, and flash meetings to coordinate daily key priorities across broader teams, including housekeeping and maintenance. Falls information was also communicated informally between staff. Senior carers and nursing staff (where employed by the home) played a key role in passing information up and down a hierarchical communication chain, including delegation, highlighting key priorities and issues. Written communication approaches varied between care homes. Information was recorded in multiple places and formats, including electronic and paper. Weekly rounds, delivered as part of the EHCH framework, were the main structure for communication with external organisations. Attendance of NHS clinicians and the location of the rounds (for instance in-person at the care home or online) varied. Some rounds were GP-led, while another was led by an Advanced Nurse Practitioner. Care homes had limited input into how these meetings were organised which impacted on workloads.

‘I would prefer it [weekly round] face-to-face I think. If they came into the home and we sat in a room and you can then go and see the resident. We have it on a Thursday and then on a Friday they come and do all the visits which means it like over 2 days… If they were here they could just walk round and assess them there and then and then it’s all done’ (Interview with care home manager).

Team cohesion

Team-working and a shared understanding of falls management was key to a successful approach according to care home staff. There were strong working relationships within and across teams. Informal chat at the start of meetings and humour when discussing challenging situations were commonly used to build and maintain relationships. However, there were occasionally tensions and divides between staff working in different roles or shift patterns.

‘And so if we spill anything we need to clean it immediately, we don’t wait for the housekeepers. Whoever is seeing the spillage needs to clean it immediately. Some will say it is the housekeeper’s responsibility but we don’t want to be like that.’ (Interview with senior carer).

Set roles

Staff worked within set roles, with senior, qualified and management staff having greater involvement in decision-making and discussions about falls. Staff working ‘on the floor’, such as carers and housekeepers knew residents well and were able to detect changes that may increase their falls risk. Their role was to escalate this information up the organisational hierarchy. Care home staff had contemporary knowledge about residents needs and preferences about falls. They advocated for residents in meetings with external services.

‘We can’t really discuss anything like that with the relatives. We get a nurse to talk to them… they need to be informed by the nurse first because if they say, “Oh we weren’t told about that” then it gets brought up.’(Interview with carer).

Variable level of involvement of residents and relatives in falls-related decision-making

The degree to which residents and relatives were involved in or informed of falls-related decision- making varied. Families were often included in conversations more than residents due to cognitive impairment. These conversations occurred at specific time points, such as following a fall or when best interests or funding decisions were required. Although considered beneficial, there appeared to be limited information to inform residents and relatives about falls risks and management strategies.

‘You get the information there if there’s something new come up… the subject of falls, no, you just take it for granted that it’s there’ (Interview with resident).

Individual level

Contextual factors at the individual level were mapped to four of the CFIR constructs and these are summarised in Table 6.

Individual awareness of risks and actions to reduce falls

Care staff were more aware of risks and actions relating to direct care tasks, such as environmental hazards, footwear and supervising mobility. Nurses, clinical leads and senior care staff tended to consider broader risks, such as the effect of health conditions and medications. Residents’ awareness related to supervision of mobility and environmental risks such as obstacles.

‘How can we prevent falls?” is a discussion topic in handover. Care staff responses- clean up spillages, footwear, make sure there aren’t any trip hazards’’ (Observation field note).

Confidence and trust in abilities

Some staff questioned their own ability to detect and respond to falls risks. This led to decisions being deferred to internal and external health professionals. Some carers were more confident than others to share their ideas about actions to support individuals or to improve falls management across the care home.

‘I think because they’ve not really been very empowered to do those assessments and got the skills that it’s then like ‘oh no someone else has to make this decision about stuff so that needs to be a professional that decides that’’ (Interview with with falls lead involved in the organisation of fall).

Experience

Staff knowledge and skills in falls management built over time until it became instinct. Witnessing falls and working with residents with complex needs could be overwhelming for staff with limited care experience. More experienced staff helped less experienced staff to develop knowledge and skills by working with them on shifts and acting as a mentor.

‘So you have those people who have been in care for years and have that experience and they can mentor the other staff. So they know instinctively if someone might be about to have a fall, do they have a UTI, do they need a med review, are they eating enough of their lunch, what is their natural behaviour, can we try fortified diet? They have all that going on in their heads but you bring in someone brand new to care and they obviously have to develop that over time.’ (Interview with care home manager).

Compassion

The compassion and motivation of staff supporting falls management was of high value to managers and residents. However due to multiple competing priorities and complexity it was perceived challenging for staff to consistently champion falls management. The resident interviewed demonstrated compassion towards each other and viewed fellow residents as family. They supported falls management to help protect each other from harm.

‘I’m more vigilant because I sit there and take it all in, I see it all happen and I can sometimes see it before the staff can see it… It’s like a mother instinct… I’ve been here eight years now – and it’s my family’ (Interview with resident).