Post on 02-Apr-2018
NORTHWEST PREVENTION & MANAGEMENT OF
INPATIENT FALLS AUDIT
APPENDICES, PART I THIS FILE CONTAINS ONLY FOUR APPENDICES.
PLEASE SEE THE PART II FOR MORE INFORMATION.
THE PAGE NUMBERING CONTINUES FROM THE MAIN REPORT.
Appendices, part I
82
Appendices, part I
This section provides data and pro formas from the case note audit as well as Trust presentations
from the June 25th network event for reference. Data and pro formas from the service evaluation are
provided in Appendix, Part II.
LIST OF APPENDICES IN PART I
PAGE
83 Summary Data Tables
104 Case Note Review Instructions & Pro forma
107 Post-Fall Audit Instructions & Pro forma
111 Trust Presentations from the June 25th Network Event
NOTE: All pro formas or questionnaires are available on request. Please contact Deborah Kenyon on
0161 419 5984 or deborah.kenyon@stockport.nhs.uk.
Summary Data Tables
83
Summary Data Tables
This section will present audit results in tables, giving counts or percentages by Trust.
LIST OF TABLES
PAGE
85 TABLE 1 - 2011 AUDIT SAMPLE BY TRUST
86 TABLE 2 - SEX AND SPECIALITY BY TRUST
87 TABLE 3 - PATIENT MOBILITY ON ADMISSION BY TRUST
88 TABLE 4 - FIRST REVIEW OF HISTORY OF FALLS BY TRUST
89 TABLE 5 - FIRST REVIEW OF GAIT/MOBILITY BY TRUST
90 TABLE 6 - FIRST REVIEW OF COGNITION BY TRUST
91 TABLE 7 - FIRST REVIEW OF PATIENT ANXIETY ABOUT FALLS BY TRUST
92 TABLE 8 - FIRST ASSESSMENT OF FALLS RISK BY TRUST
93 TABLE 9 - PATIENT’S HIGHEST RISK LEVEL DURING HOSPITAL STAY BY TRUST
94 TABLE 10 - FALLS CARE PLAN AGREED WITH PATIENT BY TRUST
95 TABLE 11 - NUMBER OF WARD TRANSFERS BY TRUST
96 TABLE 12 - RISK FACTOR BY TRUST: EYESIGHT
97 TABLE 13 - RISK FACTOR BY TRUST: HEARING
98 TABLE 14 - RISK FACTOR BY TRUST: MEDICATION
99 TABLE 15 - RISK FACTOR BY TRUST: URINALYSIS
100 TABLE 16 - RISK FACTOR BY TRUST: CONTINENCE
101 TABLE 17 - RISK FACTORS BY TRUST: MOBILITY, COGNITION
102 TABLE 18 - RISK FACTORS BY TRUST: POSTURAL HYPOTENSION, OSTEOPOROSIS
103 TABLE 19 - RISK FACTORS BY TRUST: ALTERNATIVE BEDS, BED RAILS
HOW TO READ THE TABLES
Each question is reported in a table as PERCENTAGE OF PATIENTS. Note that the sample for each ques-
tion may vary insignificantly from the final sample for each Trust as blanks were excluded by ques-
tion only.
Percentages are reported in cells which may vary in tone/colour, with darker tones/colours indicating
a higher percentage (approaching 100%) and lighter tones/colours indicating a lower percentage (ap-
proaching 0%).
Summary Data Tables
84
Example table:
NUMBER OF SMILES
NO SMILES ONE SMILE TWO
SMILES
THREE OR
MORE
SMILES
TOTAL 42% 41% 13% 4%
TRUST 1 83% 12% 5% 0%
Each question on a risk factor is categorised as ASSESSMENT, EVIDENCE, or INTERVENTION.
A Assessment of risk factor is being noted.
E Evidence of risk factor is being noted.
I Intervention for risk factor is being noted.
Whether or not a patient receives an ASSESSMENT for a risk factor depends on a Trust’s policy (and
falls intervention tool). Most Trusts stratify patients according to risk level, with the higher risk lev-
els receiving a more comprehensive list of further ASSESSMENTS.
Sometimes, a Trust provides INTERVENTIONS without doing an ASSESSMENT. If most patients
have EVIDENCE of a condition, it may be more efficient to provide INTERVENTIONS to everyone.
Most of the time, however, a Trust assesses for a risk factor, finds evidence of the risk factor, and
then provides an intervention to reduce that risk factor:
HOW TO INTERPRET THE TABLES
This data is provided in table format by Trust for reference only. Best practice guidance suggests
that Trusts should not compare falls rates against each other, as populations and incident reporting
differs significantly between Trusts. It is more meaningful to compare years for a single Trust, which
is now possible by referring to the previous falls audit reports from 2004, 2006 and 2009.
Please review this data in context of the Trust’s presentations and action plans. Please also note that
the data reported is from May 2011 and therefore may differ from current Trust practice.
Assessment of risk factor
Evidence of risk factor
Intervention for risk factor
Summary Data Tables
85
TABLE 1 - 2011 AUDIT SAMPLE BY TRUST
Trusts were asked to sample 60 patients.
A minimum sample of 40 was accepted for inclusion in the final sample.
2011 AUDIT SAMPLE
TOTAL 844
AINTREE 59
CHESTER 60
LANC TEACH 60
LEIGHTON 60
STHK 60
STOCKPORT 60
TAMESIDE 61
UHSM 60
WIRRAL 59
BOLTON 55
EAST LANC 47
SOUTHPORT 63
PENNINE 59
WIGAN 41
MACC 40
2011 AUDIT SAMPLE
Unless otherwise stated, the percentage for each question is out of the above sample for each Trust.
Note that there may be valid clinical reasons for why certain assessments or interventions are not
provided. As such, there are no standards set for the provision of assessments and care for modifia-
ble risk factors. Only ‘YES’ percentages are provided, to give some indication of provision. It is up to
individual Trusts to monitor and investigate these trends through local, topic-specific audits.
Summary Data Tables
86
TABLE 2 - SEX AND SPECIALITY BY TRUST
SEX
SPECIALITY
FEMALE MALE
MEDICINE ELDERLY ORTHOPAEDICS SURGERY
TOTAL 58% 42% TOTAL 38% 20% 21% 20%
AINTREE 58% 42% AINTREE 27% 24% 22% 27%
CHESTER 50% 50% CHESTER 48% 32% 3% 17%
LANC TEACH 57% 43% LANC TEACH 28% 8% 35% 28%
LEIGHTON 60% 40% LEIGHTON 53% 0% 23% 23%
STHK 58% 42% STHK 33% 35% 12% 20%
STOCKPORT 52% 48% STOCKPORT 23% 27% 25% 25%
TAMESIDE 59% 41% TAMESIDE 33% 0% 33% 34%
UHSM 40% 60% UHSM 25% 25% 25% 25%
WIRRAL 61% 39% WIRRAL 19% 51% 15% 15%
BOLTON 56% 44% BOLTON 36% 27% 27% 9%
EAST LANC 64% 36% EAST LANC 15% 17% 32% 36%
SOUTHPORT 58% 42% SOUTHPORT 75% 0% 12% 14%
PENNINE 65% 35% PENNINE 67% 0% 14% 19%
WIGAN 73% 27% WIGAN 12% 68% 20% 0%
MACC 70% 30% MACC 73% 5% 18% 5%
FEMALE MALE
MEDICINE ELDERLY ORTHOPAEDICS SURGERY
SEX SPECIALITY
Summary Data Tables
87
TABLE 3 - PATIENT MOBILITY ON ADMISSION BY TRUST
PATIENT MOBILITY ON ADMISSION
UNKNOWN IMMOBILE BED MOBILE WHEELCHAIR
MOBILE
RESTRICTED
(WITH AID)
RESTRICTED
(NO AID)
INDEPENDENTLY
MOBILE
TOTAL 7% 7% 5% 2% 34% 9% 37%
AINTREE 2% 0% 7% 2% 46% 5% 39%
CHESTER 2% 17% 3% 0% 18% 10% 50%
LANC TEACH 23% 7% 2% 0% 27% 12% 30%
LEIGHTON 10% 17% 15% 0% 27% 2% 30%
STHK 3% 5% 10% 2% 38% 20% 22%
STOCKPORT 0% 3% 2% 2% 40% 13% 40%
TAMESIDE 11% 2% 2% 3% 25% 10% 48%
UHSM 0% 12% 8% 0% 20% 7% 53%
WIRRAL 3% 3% 2% 2% 54% 3% 32%
BOLTON 0% 2% 5% 4% 35% 15% 40%
EAST LANC 17% 6% 0% 0% 38% 13% 26%
SOUTHPORT 17% 12% 0% 5% 29% 7% 31%
PENNINE 6% 8% 3% 0% 35% 6% 41%
WIGAN 5% 5% 2% 7% 41% 2% 37%
MACC 5% 10% 5% 0% 35% 10% 35%
UNKNOWN IMMOBILE BED MOBILE WHEELCHAIR
MOBILE
RESTRICTED
(WITH AID)
RESTRICTED
(NO AID)
INDEPENDENTLY
MOBILE
PATIENT MOBILITY ON ADMISSION
Summary Data Tables
88
TABLE 4 - FIRST REVIEW OF HISTORY OF FALLS BY TRUST
FIRST REVIEW OF HISTORY OF FALLS (DD/MM/YYYY)
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
TOTAL 1% 11% 72% 12% 3% 1%
AINTREE 2% 4% 70% 21% 2% 2%
CHESTER 2% 2% 82% 15% 0% 0%
LANC TEACH 0% 2% 80% 13% 3% 2%
LEIGHTON 0% 0% 79% 16% 5% 0%
STHK 0% 10% 69% 21% 0% 0%
STOCKPORT 0% 7% 90% 3% 0% 0%
TAMESIDE 14% 28% 28% 19% 7% 4%
UHSM 0% 0% 82% 12% 3% 3%
WIRRAL 0% 22% 65% 7% 5% 0%
BOLTON 0% 4% 93% 0% 2% 2%
EAST LANC 0% 29% 54% 7% 10% 0%
SOUTHPORT 2% 22% 66% 10% 0% 0%
PENNINE 0% 25% 56% 14% 2% 3%
WIGAN 0% 0% 90% 10% 0% 0%
MACC 0% 16% 74% 8% 3% 0%
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
FIRST REVIEW OF HISTORY OF FALLS (DD/MM/YYYY)
Summary Data Tables
89
TABLE 5 - FIRST REVIEW OF GAIT/MOBILITY BY TRUST
FIRST REVIEW OF GAIT/MOBILITY (DD/MM/YYYY)
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
TOTAL 1% 7% 69% 13% 4% 6%
AINTREE 0% 3% 63% 22% 5% 7%
CHESTER 2% 2% 82% 15% 0% 0%
LANC TEACH 0% 0% 82% 12% 5% 2%
LEIGHTON 0% 0% 77% 15% 5% 3%
STHK 2% 18% 53% 22% 3% 2%
STOCKPORT 0% 2% 93% 3% 0% 2%
TAMESIDE 10% 23% 28% 16% 7% 16%
UHSM 0% 0% 92% 5% 2% 2%
WIRRAL 0% 17% 49% 12% 5% 17%
BOLTON 0% 2% 75% 13% 9% 2%
EAST LANC 0% 11% 55% 9% 9% 17%
SOUTHPORT 0% 17% 71% 8% 0% 3%
PENNINE 0% 6% 67% 14% 2% 11%
WIGAN 0% 0% 88% 10% 0% 2%
MACC 0% 10% 65% 10% 5% 10%
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
FIRST REVIEW OF GAIT/MOBILITY (DD/MM/YYYY)
Summary Data Tables
90
TABLE 6 - FIRST REVIEW OF COGNITION BY TRUST
FIRST REVIEW OF COGNITIVE/MENTAL STATES (DD/MM/YYYY)
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
TOTAL 2% 13% 70% 10% 2% 3%
AINTREE 2% 5% 69% 17% 3% 3%
CHESTER 2% 2% 82% 15% 0% 0%
LANC TEACH 2% 0% 82% 12% 3% 2%
LEIGHTON 0% 0% 85% 8% 5% 2%
STHK 2% 33% 52% 12% 2% 0%
STOCKPORT 3% 35% 58% 0% 0% 3%
TAMESIDE 10% 30% 28% 20% 5% 8%
UHSM 0% 2% 83% 10% 3% 2%
WIRRAL 0% 32% 58% 5% 0% 5%
BOLTON 0% 2% 96% 0% 2% 0%
EAST LANC 2% 9% 68% 9% 4% 9%
SOUTHPORT 2% 19% 71% 7% 0% 2%
PENNINE 0% 6% 73% 14% 0% 6%
WIGAN 0% 2% 85% 10% 0% 2%
MACC 0% 20% 58% 8% 5% 10%
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
FIRST REVIEW OF COGNITIVE/MENTAL STATES (DD/MM/YYYY)
Summary Data Tables
91
TABLE 7 - FIRST REVIEW OF PATIENT ANXIETY ABOUT FALLS BY
TRUST
FIRST REVIEW OF ANXIOUS ABOUT FALLS (DD/MM/YYYY)
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
TOTAL 0% 74% 19% 3% 1% 2%
AINTREE 0% 93% 0% 0% 2% 5%
CHESTER 2% 77% 10% 3% 2% 7%
LANC TEACH 0% 23% 62% 10% 3% 2%
LEIGHTON 0% 100% 0% 0% 0% 0%
STHK 0% 67% 30% 2% 0% 2%
STOCKPORT 0% 78% 20% 2% 0% 0%
TAMESIDE 0% 93% 2% 2% 2% 2%
UHSM 0% 22% 62% 12% 3% 2%
WIRRAL 0% 63% 27% 2% 5% 3%
BOLTON 0% 96% 4% 0% 0% 0%
EAST LANC 0% 81% 9% 2% 2% 6%
SOUTHPORT 2% 90% 7% 0% 0% 2%
PENNINE 0% 98% 0% 0% 2% 0%
WIGAN 0% 61% 32% 5% 0% 2%
MACC 0% 60% 30% 8% 0% 3%
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
FIRST REVIEW OF ANXIOUS ABOUT FALLS (DD/MM/YYYY)
Summary Data Tables
92
TABLE 8 - FIRST ASSESSMENT OF FALLS RISK BY TRUST
FIRST ASSESSMENT OF FALLS RISK (DD/MM/YYYY)
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
TOTAL 1% 10% 67% 13% 3% 6%
AINTREE 2% 3% 54% 31% 5% 5%
CHESTER 0% 2% 82% 17% 0% 0%
LANC TEACH 0% 2% 80% 13% 3% 2%
LEIGHTON 0% 2% 70% 15% 7% 7%
STHK 0% 13% 58% 25% 0% 3%
STOCKPORT 0% 3% 92% 3% 0% 2%
TAMESIDE 11% 21% 21% 20% 8% 18%
UHSM 0% 0% 85% 10% 2% 3%
WIRRAL 0% 19% 59% 7% 5% 10%
BOLTON 0% 5% 91% 0% 2% 2%
EAST LANC 0% 43% 32% 6% 6% 13%
SOUTHPORT 0% 7% 78% 10% 2% 3%
PENNINE 0% 21% 56% 11% 2% 11%
WIGAN 0% 0% 88% 7% 0% 5%
MACC 0% 10% 65% 13% 3% 10%
UNKNOWN NO ON
ADMISSION
ON FIRST
FULL DAY
FOLLOWING
ADMISSION
ON SECOND
FULL DAY
FOLLOWING
ADMISSION
ON THE
THIRD FULL
DAY
FOLLOWING
ADMISSION
(OR LATER)
FIRST ASSESSMENT OF FALLS RISK (DD/MM/YYYY)
Summary Data Tables
93
TABLE 9 - PATIENT’S HIGHEST RISK LEVEL DURING HOSPITAL STAY
BY TRUST
PATIENT’S HIGHEST RISK LEVEL DURING THEIR HOSPITAL STAY
(BY RISK CATEGORY)
UNKNOWN NOT AT
RISK
TOTAL
AT RISK AT RISK LOW RISK
MEDIUM
RISK
HIGH
RISK
TOTAL 7% 9% 42% 5% 15% 11% 11%
AINTREE 3% 0% 97% 0% 36% 32% 29%
CHESTER 3% 5% 92% 0% 25% 28% 38%
LANC TEACH 3% 8% 88% 2% 25% 40% 22%
LEIGHTON 2% 0% 98% 0% 53% 33% 12%
STHK 10% 12% 78% 0% 25% 0% 53%
STOCKPORT 3% 0% 97% 0% 33% 23% 40%
TAMESIDE 23% 16% 61% 0% 33% 16% 11%
UHSM 12% 47% 41% 32% 7% 2% 0%
WIRRAL 24% 27% 49% 3% 19% 22% 5%
BOLTON 0% 40% 60% 60% 0% 0% 0%
EAST LANC 43% 4% 53% 0% 13% 21% 19%
SOUTHPORT 22% 0% 78% 0% 41% 30% 6%
PENNINE 7% 49% 44% 31% 2% 0% 12%
WIGAN 2% 0% 98% 0% 39% 32% 27%
MACC 18% 20% 63% 15% 25% 18% 5%
UNKNOWN NOT AT
RISK
AT RISK
(ALL) AT RISK LOW RISK
MEDIUM
RISK
HIGH
RISK
PATIENT’S HIGHEST RISK LEVEL DURING THEIR HOSPITAL STAY
(BY RISK CATEGORY)
Summary Data Tables
94
TABLE 10 - FALLS CARE PLAN AGREED WITH PATIENT BY TRUST
FALLS CARE PLAN AGREED WITH PATIENT, FAMILY OR CARER
TOTAL
YES
YES,
WRITTEN YES, VERBAL NO N/A
TOTAL 35% 18% 16% 65% 0%
AINTREE 69% 2% 68% 31% 0%
CHESTER 63% 53% 10% 37% 0%
LANC TEACH 3% 0% 3% 97% 0%
LEIGHTON 18% 2% 17% 82% 0%
STHK 35% 35% 0% 65% 0%
STOCKPORT 75% 33% 42% 25% 0%
TAMESIDE 21% 20% 2% 79% 0%
UHSM 68% 8% 60% 32% 0%
WIRRAL 17% 12% 5% 83% 0%
BOLTON 0% 0% 0% 100% 0%
EAST LANC 32% 13% 19% 68% 0%
SOUTHPORT 11% 11% 0% 89% 0%
PENNINE 27% 22% 5% 71% 2%
WIGAN 51% 44% 7% 49% 0%
MACC 33% 33% 0% 68% 0%
TOTAL
YES
YES,
WRITTEN YES, VERBAL NO N/A
FALLS CARE PLAN AGREED WITH PATIENT, FAMILY OR CARER
Summary Data Tables
95
TABLE 11 - NUMBER OF WARD TRANSFERS BY TRUST
NUMBER OF WARD TRANSFERS
NO WARD
TRANSFERS
ONE
WARD
TRANSFER
TWO
WARD
TRANSFERS
THREE
OR MORE
WARD
TRANSFERS
TOTAL 42% 41% 13% 4%
AINTREE 83% 12% 5% 0%
CHESTER 58% 32% 7% 3%
LANC TEACH 48% 32% 17% 3%
LEIGHTON 20% 60% 18% 2%
STHK 36% 44% 17% 3%
STOCKPORT 22% 43% 25% 10%
TAMESIDE 31% 31% 23% 15%
UHSM 50% 47% 3% 0%
WIRRAL 32% 59% 9% 0%
BOLTON 33% 56% 9% 2%
EAST LANC 55% 38% 6% 0%
SOUTHPORT 63% 20% 15% 2%
PENNINE 31% 52% 15% 3%
WIGAN 24% 62% 10% 3%
MACC 43% 33% 20% 5%
NO WARD
TRANSFERS
ONE
WARD
TRANSFER
TWO
WARD
TRANSFERS
THREE
OR MORE
WARD
TRANSFERS
NUMBER OF WARD TRANSFERS
Summary Data Tables
96
TABLE 12 - RISK FACTOR BY TRUST: EYESIGHT
A E I I I
WA
S EY
ESIG
HT C
HEC
KED
?
(OB
JEC
TS A
T A
DIS
TA
NCE,
EYES
IGH
T C
HA
RT)
WA
S TH
ERE
EVID
ENCE
OF
PO
OR
EY
ESIG
HT?
(WIT
H C
UR
REN
T E
YEW
EAR
)
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
SIG
HT A
ID?
WA
S TH
E P
ATIE
NT R
EFER
RED
FOR
A V
ISIO
N T
EST?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
EYES
IGH
T?
YES YES YES YES YES
TOTAL 25% 22% 13% 1% 13%
AINTREE 17% 14% 8% 3% 10%
CHESTER 32% 12% 0% 0% 0%
LANC TEACH 2% 13% 5% 0% 5%
LEIGHTON 0% 13% 7% 0% 7%
STHK 10% 3% 17% 0% 17%
STOCKPORT 10% 17% 0% 0% 0%
TAMESIDE 16% 13% 5% 0% 5%
UHSM 83% 17% 7% 0% 7%
WIRRAL 22% 37% 23% 0% 22%
BOLTON 62% 18% 2% 2% 2%
EAST LANC 28% 22% 15% 0% 15%
SOUTHPORT 27% 41% 40% 0% 39%
PENNINE 0% 55% 43% 0% 41%
WIGAN 59% 37% 5% 0% 5%
MACC 25% 25% 10% 5% 10%
YES YES YES YES YES
WA
S EY
ESIG
HT C
HEC
KED
?
(OB
JEC
TS A
T A
DIS
TA
NCE,
EYES
IGH
T C
HA
RT)
WA
S TH
ERE
EVID
ENCE
OF
PO
OR
EY
ESIG
HT?
(WIT
H C
UR
REN
T E
YEW
EAR
)
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
SIG
HT A
ID?
WA
S TH
E P
ATIE
NT R
EFER
RED
FOR
A V
ISIO
N T
EST?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
EYES
IGH
T?
A E I I I
Summary Data Tables
97
TABLE 13 - RISK FACTOR BY TRUST: HEARING
A E I I I
WA
S H
EAR
ING
CH
ECK
ED?
WA
S TH
ERE
EVID
ENCE
OF
PO
OR
HEA
RIN
G?
(WIT
H A
ID
IN W
OR
KIN
G O
RD
ER)
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
HEA
RIN
G A
ID?
WA
S TH
E P
ATIE
NT R
EFER
RED
FOR
A H
EAR
ING
TES
T/A
ID?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
HEA
RIN
G?
YES YES YES YES YES
TOTAL 30% 15% 6% 0% 6%
AINTREE 93% 14% 7% 0% 7%
CHESTER 15% 17% 2% 0% 2%
LANC TEACH 3% 10% 2% 0% 2%
LEIGHTON 2% 13% 5% 0% 5%
STHK 8% 3% 2% 0% 2%
STOCKPORT 7% 3% 0% 0% 0%
TAMESIDE 28% 10% 5% 0% 5%
UHSM 72% 10% 3% 0% 3%
WIRRAL 19% 17% 7% 0% 7%
BOLTON 65% 31% 13% 0% 13%
EAST LANC 26% 15% 9% 0% 9%
SOUTHPORT 31% 19% 15% 0% 15%
PENNINE 2% 23% 6% 0% 6%
WIGAN 59% 24% 2% 0% 2%
MACC 33% 15% 10% 5% 10%
YES YES YES YES YES
WA
S H
EAR
ING
CH
ECK
ED?
WA
S TH
ERE
EVID
ENCE
OF
PO
OR
HEA
RIN
G?
(WIT
H A
ID
IN W
OR
KIN
G O
RD
ER)
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
HEA
RIN
G A
ID?
WA
S TH
E P
ATIE
NT R
EFER
RED
FOR
A H
EAR
ING
TES
T/A
ID?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
HEA
RIN
G?
A E I I I
Summary Data Tables
98
TABLE 14 - RISK FACTOR BY TRUST: MEDICATION
E E E E E E A I
WA
S TH
E P
ATIE
NT O
N
PSY
CH
OTR
OP
IC
MED
ICA
TIO
NS?
WA
S TH
E P
ATIE
NT O
N
SED
ATIV
E M
EDIC
ATIO
NS?
WA
S TH
E P
ATIE
NT O
N
CA
RD
IAC M
EDIC
ATIO
NS?
WA
S TH
E P
ATIE
NT O
N
BO
NE-
STR
ENG
TH
ENIN
G
MED
ICA
TIO
NS?
WA
S TH
E P
ATIE
NT O
N
AN
TIB
IOTI
CS?
WA
S TH
E P
ATIE
NT O
N
FOU
R O
R M
OR
E
MED
ICA
TIO
NS?
WA
S TH
ERE
A R
ISK
/BEN
EFIT
REV
IEW
OF
ALL
MED
ICA
TIO
N?
IF Y
ES,
DID
TH
IS R
ESU
LT I
N A
CH
AN
GE
IN M
EDIC
ATIO
NS?
YES YES YES YES YES YES YES YES
TOTAL 26% 25% 66% 24% 50% 88% 44% 30%
AINTREE 39% 32% 59% 27% 44% 88% 15% 12%
CHESTER 40% 17% 30% 32% 58% 95% 98% 92%
LANC TEACH 23% 42% 52% 10% 48% 73% 45% 35%
LEIGHTON 40% 13% 83% 18% 38% 87% 93% 25%
STHK 17% 20% 75% 30% 62% 98% 75% 40%
STOCKPORT 27% 25% 62% 15% 28% 83% 45% 34%
TAMESIDE 28% 25% 66% 33% 59% 92% 31% 31%
UHSM 33% 50% 75% 27% 50% 85% 33% 27%
WIRRAL 20% 24% 75% 32% 39% 88% 53% 35%
BOLTON 31% 15% 76% 31% 49% 87% 2% 2%
EAST LANC 30% 32% 66% 9% 34% 85% 23% 17%
SOUTHPORT 15% 3% 68% 14% 51% 83% 31% 14%
PENNINE 6% 32% 49% 27% 57% 87% 5% 5%
WIGAN 27% 10% 83% 30% 71% 95% 56% 48%
MACC 13% 25% 83% 23% 70% 95% 58% 32%
YES YES YES YES YES YES YES YES
WA
S TH
E P
ATIE
NT O
N
PSY
CH
OTR
OP
IC
MED
ICA
TIO
NS?
WA
S TH
E P
ATIE
NT O
N
SED
ATIV
E M
EDIC
ATIO
NS?
WA
S TH
E P
ATIE
NT O
N
CA
RD
IAC M
EDIC
ATIO
NS?
WA
S TH
E P
ATIE
NT O
N
BO
NE-
STR
ENG
TH
ENIN
G
MED
ICA
TIO
NS?
WA
S TH
E P
ATIE
NT O
N
AN
TIB
IOTI
CS?
WA
S TH
E P
ATIE
NT O
N
FOU
R O
R M
OR
E
MED
ICA
TIO
NS?
WA
S TH
ERE
A R
ISK
/BEN
EFIT
REV
IEW
OF
ALL
MED
ICA
TIO
N?
IF Y
ES,
DID
TH
IS R
ESU
LT I
N A
CH
AN
GE
IN M
EDIC
ATIO
NS?
E E E E E E A I
Summary Data Tables
99
TABLE 15 - RISK FACTOR BY TRUST: URINALYSIS
A E A I
WA
S A
UR
INA
LYSI
S
PER
FOR
MED
?
WA
S A
N I
NFE
CTIO
N
CO
NFI
RM
ED?
WER
E FU
RTH
ER
INV
ESTIG
ATIO
NS
PER
FOR
MED
?
WA
S TH
E P
ATIE
NT T
REA
TED
FOR
TH
E IN
FECTIO
N?
YES YES YES YES
TOTAL 49% 15% 14% 16%
AINTREE 49% 12% 8% 10%
CHESTER 63% 19% 25% 14%
LANC TEACH 32% 8% 3% 7%
LEIGHTON 43% 23% 5% 23%
STHK 65% 15% 30% 25%
STOCKPORT 23% 7% 10% 7%
TAMESIDE 61% 10% 10% 10%
UHSM 33% 7% 5% 7%
WIRRAL 63% 19% 26% 18%
BOLTON 62% 15% 2% 17%
EAST LANC 43% 13% 9% 19%
SOUTHPORT 47% 12% 7% 12%
PENNINE 48% 18% 26% 21%
WIGAN 44% 29% 12% 29%
MACC 66% 37% 32% 37%
YES YES YES YES
WA
S A
UR
INA
LYSI
S
PER
FOR
MED
?
WA
S A
N I
NFE
CTIO
N
CO
NFI
RM
ED?
WER
E FU
RTH
ER
INV
ESTIG
ATIO
NS
PER
FOR
MED
?
WA
S TH
E P
ATIE
NT T
REA
TED
FOR
TH
E IN
FECTIO
N?
A E A I
Summary Data Tables
100
TABLE 16 - RISK FACTOR BY TRUST: CONTINENCE
A E I E I
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
CO
NTI
NEN
CE?
DID
TH
E P
ATIE
NT H
AV
E A
NY
CO
NTI
NEN
CE
PR
OB
LEM
S?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
DV
ICE
ON
TO
ILET
PLA
NN
ING
?
WA
S TH
E P
ATIE
NT
CA
TH
ETER
ISED
?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
CO
NTI
NEN
CE?
YES YES YES YES YES
TOTAL 82% 27% 14% 23% 31%
AINTREE 97% 22% 10% 25% 34%
CHESTER 85% 46% 19% 29% 43%
LANC TEACH 80% 15% 17% 10% 20%
LEIGHTON 78% 30% 5% 22% 25%
STHK 30% 32% 3% 18% 22%
STOCKPORT 83% 35% 5% 20% 22%
TAMESIDE 56% 10% 13% 26% 31%
UHSM 100% 20% 7% 23% 28%
WIRRAL 91% 27% 9% 18% 25%
BOLTON 96% 29% 0% 29% 29%
EAST LANC 70% 17% 15% 28% 36%
SOUTHPORT 90% 32% 24% 19% 27%
PENNINE 94% 29% 13% 29% 40%
WIGAN 100% 34% 56% 27% 63%
MACC 90% 23% 25% 18% 38%
YES YES YES YES YES
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
CO
NTI
NEN
CE?
DID
TH
E P
ATIE
NT H
AV
E A
NY
CO
NTI
NEN
CE
PR
OB
LEM
S?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
DV
ICE
ON
TO
ILET
PLA
NN
ING
?
WA
S TH
E P
ATIE
NT
CA
TH
ETER
ISED
?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N I
NTER
VEN
TIO
N F
OR
CO
NTI
NEN
CE?
A E I E I
Summary Data Tables
101
TABLE 17 - RISK FACTORS BY TRUST: MOBILITY, COGNITION
A I
E E
WA
S TH
E P
ATIE
NT R
EVIE
WED
BY
A P
HY
SIO
THER
AP
IST?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
MO
VIN
G/H
AN
DLI
NG
PLA
N?
DID
TH
E P
ATIE
NT H
AV
E
DEM
ENTIA
?
WA
S TH
E P
ATIE
NT D
ELIR
IOU
S
OR
CO
NFU
SED
?
YES YES YES YES
TOTAL 65% 59% TOTAL 13% 26%
AINTREE 71% 17% AINTREE 24% 24%
CHESTER 62% 60% CHESTER 5% 20%
LANC TEACH 73% 72% LANC TEACH 8% 12%
LEIGHTON 58% 65% LEIGHTON 10% 22%
STHK 49% 70% STHK 10% 36%
STOCKPORT 63% 77% STOCKPORT 8% 22%
TAMESIDE 75% 72% TAMESIDE 15% 18%
UHSM 58% 97% UHSM 10% 18%
WIRRAL 66% 46% WIRRAL 9% 24%
BOLTON 78% 0% BOLTON 20% 45%
EAST LANC 74% 79% EAST LANC 17% 23%
SOUTHPORT 47% 56% SOUTHPORT 20% 20%
PENNINE 73% 42% PENNINE 10% 32%
WIGAN 59% 71% WIGAN 18% 37%
MACC 73% 78% MACC 18% 43%
YES YES YES YES
WA
S TH
E P
ATIE
NT R
EVIE
WED
BY
A P
HY
SIO
THER
AP
IST?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
MO
VIN
G/H
AN
DLI
NG
PLA
N?
DID
TH
E P
ATIE
NT H
AV
E
DEM
ENTIA
?
WA
S TH
E P
ATIE
NT D
ELIR
IOU
S
OR
CO
NFU
SED
?
A I
E E
Summary Data Tables
102
TABLE 18 - RISK FACTORS BY TRUST: POSTURAL HYPOTENSION, OS-
TEOPOROSIS
A E I
A
WA
S LY
ING
AN
D S
TAN
DIN
G
BLO
OD
PR
ESSU
RE
TA
KEN
?
WA
S TH
ERE
EVID
ENCE
OF
PO
STU
RA
L H
YP
OTEN
SIO
N?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
DV
ICE
ON
HO
W T
O
PR
EVEN
T S
YM
PTO
MS
OF
PO
STU
RA
L H
YP
OTEN
SIO
N?
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
OST
EOP
OR
OSI
S?
(IN
CLU
DIN
G R
EFER
RA
LS)
YES YES YES YES
TOTAL 8% 4% 2% TOTAL 6%
AINTREE 8% 0% 0% AINTREE 7%
CHESTER 9% 5% 4% CHESTER 5%
LANC TEACH 0% 0% 0% LANC TEACH 3%
LEIGHTON 5% 5% 0% LEIGHTON 2%
STHK 15% 7% 3% STHK 0%
STOCKPORT 13% 2% 0% STOCKPORT 8%
TAMESIDE 7% 2% 2% TAMESIDE 10%
UHSM 8% 6% 4% UHSM 12%
WIRRAL 8% 3% 2% WIRRAL 8%
BOLTON 0% 4% 0% BOLTON 13%
EAST LANC 13% 6% 4% EAST LANC 2%
SOUTHPORT 2% 0% 0% SOUTHPORT 0%
PENNINE 2% 10% 0% PENNINE 0%
WIGAN 7% 0% 2% WIGAN 15%
MACC 30% 10% 5% MACC 15%
YES YES YES YES
WA
S LY
ING
AN
D S
TAN
DIN
G
BLO
OD
PR
ESSU
RE
TA
KEN
?
WA
S TH
ERE
EVID
ENCE
OF
PO
STU
RA
L H
YP
OTEN
SIO
N?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
DV
ICE
ON
HO
W T
O
PR
EVEN
T S
YM
PTO
MS
OF
PO
STU
RA
L H
YP
OTEN
SIO
N?
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
OST
EOP
OR
OSI
S?
(IN
CLU
DIN
G R
EFER
RA
LS)
A E I
A
Summary Data Tables
103
TABLE 19 - RISK FACTORS BY TRUST: ALTERNATIVE BEDS, BED
RAILS
A I
A I
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
ALT
ERN
ATIV
E B
EDS?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N A
LTER
NA
TIV
E B
ED?
WA
S TH
E P
ATIE
NT’S
NEE
D
FOR
BED
RA
ILS
ASS
ESSE
D?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
BED
RA
IL P
LAN
?
YES YES YES YES
TOTAL 33% 14% TOTAL 55% 32%
AINTREE 5% 2% AINTREE 29% 12%
CHESTER 45% 28% CHESTER 80% 54%
LANC TEACH 68% 27% LANC TEACH 77% 37%
LEIGHTON 12% 3% LEIGHTON 63% 58%
STHK 2% NA* STHK 93% 63%
STOCKPORT 35% 10% STOCKPORT 43% 32%
TAMESIDE 13% 0% TAMESIDE 43% 21%
UHSM 43% 17% UHSM 85% 50%
WIRRAL 47% 3% WIRRAL 54% 17%
BOLTON 69% 24% BOLTON 25% 7%
EAST LANC 13% 4% EAST LANC 28% 13%
SOUTHPORT 3% 2% SOUTHPORT 17% 8%
PENNINE 25% 23% PENNINE 25% 17%
WIGAN 61% 29% WIGAN 98% 68%
MACC 65% 43% MACC 68% 28%
YES YES YES YES
WA
S TH
E P
ATIE
NT A
SSES
SED
FOR
ALT
ERN
ATIV
E B
EDS?
WA
S TH
E P
ATIE
NT P
RO
VID
ED
WIT
H A
N A
LTER
NA
TIV
E B
ED?
WA
S TH
E P
ATIE
NT’S
NEE
D
FOR
BED
RA
ILS
ASS
ESSE
D?
WA
S TH
E P
ATIE
NT*
PR
OV
IDED
WIT
H A
BED
RA
IL P
LAN
?
A I
A I
Key: PURPLE indicates that a question was not applicable to this Trust.
* STHK provides alternative beds to all patients.
Case Note Review Instructions & Pro forma
104
Case Note Review Instructions & Pro forma
CASE NOTE REVIEW - PRO FORMA INSTRUCTIONS
Post-Fall Audit Instructions & Pro forma
107
Post-Fall Audit Instructions & Pro forma
POST-FALL AUDIT - PRO FORMA INSTRUCTIONS
Trust Presentations from the June 25th Network Event
111
Trust Presentations from the June 25th Network Event
Acute Trusts were invited to present a summary of their results and either a SWOT analysis
(strengths, weaknesses, opportunities, threats) or an action plan as part of the network event on
June 25th (2011). These presentations are provided for reference.
LIST OF PRESENTATIONS
PAGE
112 PRESENTATION 1 - AINTREE UNIVERSITY HOSPITALS NHS FT
113 PRESENTATION 2 - EAST LANCASHIRE HOSPITALS NHS TRUST
114 PRESENTATION 3 - LANCASHIRE TEACHING HOSPITALS NHS FT
115 PRESENTATION 4 - EAST CHESHIRE NHS TRUST
116 PRESENTATION 5 - MID-CHESHIRE HOSPITALS NHS FT
118 PRESENTATION 6 - ST HELENS & KNOWSLEY HOSPITALS NHS TRUST
119 PRESENTATION 7 - STOCKPORT NHS FT
120 PRESENTATION 8 - UNIVERSITY HOSPITAL OF SOUTH MANCHESTER NHS FT
123 PRESENTATION 9 - TAMESIDE HOSPITAL NHS FT
124 PRESENTATION 10 - WRIGHTINGTON, WIGAN AND LEIGH NHS FT