Sample policy · Adult social care

Falls prevention and management policy (adult social care)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 17 (good governance) and Regulation 20 (duty of candour). · primary source

1. What the regulation says

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that the premises used by the service provider are safe to use for their intended purpose and are used in a safe way, (Reg 12(2)(d) (premises safety))

ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))

The full text of the regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations.

For falls, this means the service must assess each person's falls risk, do all that is reasonably practicable to reduce avoidable risk, keep premises and equipment safe, respond appropriately after a fall, and review patterns so the service keeps learning.

3. Purpose

This policy sets out how the Service assesses falls risk, reduces avoidable risk, responds after a fall and learns from falls patterns across the Service.

The Service must verify this policy against current NICE falls guidance, CQC source material, local falls pathway and local emergency escalation routes before adoption.

4. Sources to verify before adoption

5. Scope

This policy applies to:

The Service treats falls as a safety, care-planning and governance issue. A fall is not treated as inevitable because a person is older, frail or living with dementia.

5.1 Roles and responsibilities

6. Falls prevention and response workflow

For every new risk, near fall or fall, staff use this workflow:

  1. Protect and assess: make the person and area safe, identify urgent clinical concerns and follow the local post-fall protocol.
  2. Record the event: enter the facts, observations, advice, contacts and immediate actions as soon as practicable, normally before the end of the shift.
  3. Reassess risk: update the comprehensive falls assessment and care plan rather than relying on a prediction score alone.
  4. Assign controls: name the person responsible for environmental, equipment, medicines, mobility or referral action and set a review date.
  5. Check effectiveness: confirm whether each action was completed and whether risk, confidence or mobility changed.
  6. Review patterns: link repeat events to the risk register and governance review so recurring causes are not managed as isolated falls.

6.1 Falls risk assessment

The Service completes a falls risk assessment:

The assessment considers:

The Service verifies the assessment content against current NICE guidance and local falls pathway before adoption.

7. Environmental risk factors

Staff check the environment for avoidable falls risk.

Checks include:

Environmental risks are recorded in the care plan or premises record and assigned to an owner for action.

8. Mobility and footwear assessment

The care plan records the person's mobility, transfer support and footwear needs.

The assessment includes:

Staff seek occupational therapy, physiotherapy, podiatry or GP input where risk cannot be managed by routine care planning.

9. Post-fall management

After a fall or suspected fall, staff:

  1. stay with the person and make the area safe
  2. assess for immediate danger within their training
  3. do not move the person until safe to do so
  4. call emergency services where required by clinical presentation or local protocol
  5. seek senior staff or clinical advice where the person is injured, unwell, taking anticoagulants or cannot give a reliable account
  6. record observations and actions taken
  7. inform the Registered Manager or senior person on duty
  8. inform family or representative according to the care plan and consent position
  9. record the fall in the incident register
  10. review the care plan and falls risk assessment

The Service does not use this policy as a clinical algorithm. Staff follow current first-aid training, local falls pathway and emergency escalation advice.

10. Medical escalation criteria

Staff seek urgent medical advice or emergency support where the person's presentation, injury, symptoms or history indicates risk.

The local post-fall protocol includes escalation prompts for:

The Service verifies these prompts against current local NHS falls pathway and clinical advice before adoption.

11. Documentation

The incident record includes:

Staff record facts and avoid blame language.

12. Pattern detection across the Service

The Registered Manager reviews falls patterns at least monthly.

The review considers:

Patterns are reported to the governance group and converted into improvement actions where needed.

13. Multi-disciplinary input

The Service seeks input from relevant professionals where falls risk is repeated, complex or increasing.

This may include:

The care plan records advice received and whether it was implemented.

14. Equipment, adaptations and falls champion

The Service keeps equipment and adaptations under review.

Equipment may include:

The falls champion supports staff practice by:

The falls champion does not replace the Registered Manager's accountability.

15. Audit cadence

The Registered Manager audits falls practice at least quarterly.

The audit sample includes:

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

15.1 Related policies and records

16. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

17. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

18. Document control

Version Date Author Changes
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.
v1.1 2026-07-19 Verivius (sample) Updated the NICE anchor and added named ownership, an end-to-end workflow and linked companion policies.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

Falls are where a small gap in the record turns into real harm quickly. A person taking an anticoagulant who is found on the floor with nobody witnessing it can look completely well for hours while a slow bleed develops, so a prompt, factual post-fall record earns its keep clinically long before anyone inspects it: it is what the paramedic, the out-of-hours doctor and the family rely on. The quieter risk comes later. After one fall many people stop walking to the toilet or to the lounge, lose strength and confidence, and become more likely to fall again, so a fall that is logged but never turned into a changed care plan tends to cost the person their independence rather than only their balance. Falls also cluster in ways that individual incident forms hide, around a shift change, one corridor at night, or the fortnight after a medicine change, and only pattern review across the whole service brings that into view. Treating a fall as inevitable because someone is older, frail or living with dementia is the single assumption that stops all of this working.

  1. After a fall, the person is escalated for urgent medical review where their presentation demands it, particularly a possible head injury, a person taking anticoagulant medicines, or an unwitnessed fall, and that decision is recorded. What goes wrong is a slow bleed or a fracture missed because nobody escalated.

    Strong evidence: The post-fall steps requiring staff to seek senior or clinical advice where the person is injured, unwell, taking anticoagulants or cannot give a reliable account (Section 9), and the local escalation prompts for suspected head injury, loss of consciousness, suspected fracture and anticoagulant use (Section 10), with medical advice sought recorded in the incident record (Section 11). The quarterly audit samples medical escalation decisions (Section 15).

    Weak evidence: Post-fall records where the medical advice field says "monitored" or "no injury seen" and nothing else, with no note of whether the person takes an anticoagulant and no observations recorded for an unwitnessed fall. The tell is that only decisions to escalate are written down: where staff decided the person did not need urgent review, the reasoning is missing entirely, so the next colleague on shift cannot tell whether the presentation was actually considered.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  2. A fall actually changes the person's care rather than only being logged. Without that, the same person falls again because the comprehensive falls assessment and care plan were never updated and no control was owned.

    Strong evidence: The workflow step to reassess risk by updating the comprehensive falls assessment and care plan rather than relying on a prediction score alone, and to assign named controls with a review date (Section 6), plus the post-fall step to review the care plan and falls risk assessment (Section 9).

    Weak evidence: The incident form has "care plan reviewed" ticked, but the falls risk assessment and care plan were last edited on admission even though the person has fallen three times since. Actions read as the same generic line after every fall, for example "encourage to use frame", with no named owner, no review date and no record of whether the previous action was ever completed or made any difference.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 12(2)(a) and (b) (with reg 9(3)(a)-(b))

  3. Repeat and unwitnessed falls are pulled together and traced to a cause, not managed as isolated incidents. What gets missed is a recurring pattern (a time of day, a location, a staffing gap, a medicine change) that nobody has joined up, so the same people keep falling for the same reason.

    Strong evidence: The monthly pattern review of time of day, location, staff deployment, medication changes, equipment issues, repeat falls and unwitnessed falls, with repeat events linked to the risk register and reported to the governance group as improvement actions (Sections 6 and 12).

    Weak evidence: Falls exist only as a monthly count on a quality dashboard, "nine falls, no injuries", with no breakdown by person, time of day or location, and no separation of repeat fallers or unwitnessed falls. Governance minutes record that falls were discussed but carry no theme, action, owner or date, and no repeat pattern has ever reached the risk register.

    What the regulator expects to see. Not a law in itself, but CQC judges you against it, so an inspector will look for it and expect a reason where you depart from it.

  4. A falls risk assessment is completed at the moments that matter (after a fall, after a medicine change, after hospital discharge, after delirium or infection), not just once on admission, and a fall is not treated as inevitable because a person is older or frail. What goes wrong is a missed reassessment after a medicine change that raised the person's falls risk.

    Strong evidence: The falls risk assessment triggers and content, including after medication change that may affect mobility, alertness or blood pressure and after illness, infection or delirium (Section 6.1), the medicines lead coordinating a medicines review where a fall may relate to sedation, dizziness or a recent medicine change (Section 5.1), and the policy position that a fall is not treated as inevitable because a person is older, frail or living with dementia (Section 5).

    Weak evidence: One falls risk assessment dated on admission and never repeated, or reassessment triggered only by an actual fall and never by a new sedative, diuretic or blood-pressure medicine, a return from hospital, or an episode of delirium or infection. Weaker still is a single risk score recorded as a number with none of the underlying content, alongside daily notes that explain falls away as expected because the person is frail or living with dementia.

    The recognised standard from a professional or clinical body, such as NICE or a royal college. Not a legal duty, but the accepted mark of safe practice, and a departure needs a documented reason.

  5. The fall is written up promptly and completely, not filled in from memory days later. The gap that shows up later is an incident record missing whether the fall was witnessed, the observations taken, or whether family were told.

    Strong evidence: The requirement to record the event as soon as practicable, normally before the end of the shift (Section 6), and the incident record contents covering date, time and location, whether the fall was witnessed, injuries or symptoms, observations taken, medical advice sought and family or representative contact (Section 11).

    Weak evidence: Records clearly written up after the event from memory or from a handover note, with estimated times, "found on floor" and little else, and the witnessed or unwitnessed field left blank or marked unknown. Observations and family or representative contact are empty with no note of whether the person wanted them told, and the account slips into blame language about the person not following instructions rather than the facts of what happened.

    Our recommended baseline. Not a legal or regulatory requirement, but a sensible standard we suggest where the rules leave the detail to you. Adapt it to your service.

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Last verified 20 July 2026

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Last reviewed 19 July 2026