Falls - factors to consider

As we age, or after an illness or accident, it is common for mobility to deteriorate which can lead to falls, loss of confidence and reduced independence. For some, this may be a temporary period on the path to recovery; for others, it may be an ongoing hazard requiring management over the long-term. Many people attending our hospitals have been admitted due to falling, poor balance/gait and/or have had a fall in the last 6 months, this is one of the strongest risk factors for further falls. 

It is important that the usual level of mobility is known. Keeping moving and being active is an important part of recovery and should be actively encouraged, this can prevent deconditioning, reduce the risk of falls and length of hospital stay.

If a patient has a history of falls they are often at increased risk of falling again, particularly when in hospital.  Healthcare professionals must routinely ask the people they come in to contact with whether they have fallen in the past 6 months and where applicable asked about the frequency, context and characteristics of the fall/s.  Recurrent falls are considered to be two or more in the previous 12 months (NG249 2025).

A detailed falls history can help reduce the risk of future falls as this helps with identification of patterns of falls, frequency of falls and any triggers (deterioration/reason for admission to hospital, change in medication, life events, and functional decline).

Providing good support for people with cognitive impairment is imperative to reducing the risk of falls and improving safety awareness.

It is recognised that the safety of patients with cognitive impairment can be adversely affected by increased changes in ward environment (changing ward/hospital or even moving bed space); therefore this movement must be minimised. All patients with cognitive impairment should have a cognitive impairment care plan in place to support the management of falls risk.

If the person has dementia, explore what is normal for the person and ask the family and carers to complete the ‘Getting to Know Me’ document with the person.

Cognitive impairment is a known major risk factor contributing to a patient experiencing a fall and any cause for distress and agitation should be investigated and managed.

If a patient is presenting with symptoms of stress and distress (such as verbal and physical aggression, anxiety, agitation and taking risks with mobility etc.) then refer to and use the Stress and Distress Care Plan to support the de-escalation and management of stressed and distressed behaviour. In mental health settings there should be a detailed care plan in place to manage stress and distress. Where there is a behavioural component to falls this should be stated in the behavioural management plan and interventions to manage falls included. An early referral to Elderly Mental Health Team should be considered to manage the patient and give advice.

Stress and distress may be an indicator of postural hypotension and this could be a key reason for falls. If an individual displays stress and distress during functional activity such as transfers it is recommended to review lying and standing blood pressure.

Consideration should be given to the effects of alcohol withdrawal combined with risk taking behaviour and mobility.

The 4AT is a screening instrument designed for rapid and sensitive initial assessment of cognitive impairment and delirium. If delirium is identified, an assessment, treatment and management plan must be put in place -TIME Bundle and Delirium Care Plan should be in place. Maintain a calm, relaxed manner and use the person’s name when working with them as this will help reassure them. Engage with patient / family or carers and explain what delirium is and how it is affecting the person and provide information.

As part of the Delirium pathway there is the Delirium Immediate care guidance - TIME Bundle. Access Athena for more information and guidance on delirium management and to access the 4ATscreening instrument for cognitive impairment and delirium.

Acute wards can complete a 2 hourly behavior monitoring chart to monitor risk taking, patterns of behavior and as an aid to the level of supervision required.

During hospitalisation, older people may experience significant functional decline which impairs their future independence and quality of life. Even a minor illness can have a significant impact on functional decline, recovery time and ability to regain full independence. Muscle strength is vital for activities such as walking, getting up from a chair, out of bed or climbing stairs. Physical activity and exercise can help combat the loss of essential muscle and bone density which accompanies ageing. Encouraging people to take part in functional activities of daily living such as washing, dressing, sitting up for meals etc. can help people maintain independence while they are in hospital.

Recovery, independence and rehabilitation must be considered throughout the patient journey. Appendix 1 highlights the importance of early mobilisation to help to build confidence and maintain or regain mobility. A mobility assessment must be completed as part of the care plan at the earliest opportunity during admission.

Mobility should be prioritised and patient placement on the ward considered, to encourage mobility to the bathroom. Patients should be encouraged to change position (sit to stand) and move as part of their care rounding. Ward safety briefs should incorporate a discussion about active wards and encouraging mobility.

In mental health settings similar challenges can arise due to acute mental illness leading to lethargy, poor motivation, withdrawal and inactivity. This can lead to long periods of inactivity in a seated position and a reluctance to mobilise or pursue activity. Every opportunity should be taken to encourage mobility/activity as this can have a direct impact on improving both physical and mental health.

Dual task activities such as walking and talking to staff at the same time can increase the risk of falls. This is particularly significant if a patient has a visual, hearing or cognitive impairment.

• Falls prevention messages must be shared in a positive way; emphasising the benefits of interventions – enhancing health, independence and quality of life.
• Make sure, if appropriate, walking aids and suitable footwear are available.
• Plan a routine to encourage activity as research shows that breaking long periods of sitting at least every hour has a positive effect on health.
• If someone has lost confidence or has problems with mobility or balance involve the physiotherapist if required for a full assessment.
• Interventions which will provide benefit on discharge from hospital must be initiated and introduced while the patient is in hospital care.
• Discuss community falls services (e.g. further rehabilitation, Community strength and balance classes run by local Leisure services) with the person and multidisciplinary team and ensure appropriate falls prevention and management follow up is in place.

Deconditioning

Deconditioning is defined as a complex process of physiological and psychological changes that lead to functional decline following a period of inactivity, bed rest, or a sedentary lifestyle. Deconditioning can start within the first day of hospitalisation.

It is estimated that older patients can spend over 90% of their time being sedentary during their hospital stay. Muscle strength can reduce by 2-5% in first 24 hours of immobility, with up to 20-30% in first week. Joint contractures can begin to form within as little as 8 hours of immobility.

A recent systemic review found that irrespective of the reason for admission 87-100% of patients spend their time lying down or sitting, with many taking less than 1000 steps per day. Patients that remain in bed are up to 16 times more likely to experience constipation than those who are mobile and increases risk of pneumonia and thromboembolism, and the main risk factors for pressure ulcers. Those who have fallen or have a fear of falling will benefit from physical activity to increase their confidence and improve their strength and balance. All patients should be encouraged to get up from bed, get dressed and get moving as often as able to reduce the risk of deconditioning.

Frailty

Frailty is a complex condition associated with the development of multiple long-term conditions. When a person is living with frailty, their body gradually loses its in-built reserves. This leaves them vulnerable to changes in their health or circumstances, and makes it harder to recover from injury, infection or illness. People living with frailty may experience falls, immobility, delirium, incontinence and are more susceptible to side effects of medication.

As a person’s frailty increases, they may find it more difficult to live independently, require additional support and care, and are more likely to be admitted to hospital. Evidence shows that between 30-56% of older people living with frailty experience a reduction in their physical ability between admission and discharge.

The Rockwood Clinical Frailty Scale is used within NHSAA acute hospitals.

Frailty is not an inevitable consequence of ageing, although older people living with frailty are amongst the most vulnerable in our society. They can be at risk of harm if we do not understand and address their needs, or if our systems and services are inadequate, ineffective or poorly coordinated. Coordinated multiagency care supports and enables people experiencing frailty to remain as independent as possible. If frailty, or likelihood of frailty, is identified early, it can sometimes be prevented, reversed or slowed down.

Ageing and frailty standards – Healthcare Improvement Scotland 

Fear of falling could potentially negatively influence mobility, physical activity and functional performance in adults. An active ward where mobility is encouraged can help to build a patients confidence in a supported environment. This will help their recovery and ability to return home.

Fear of falling can affect activities of daily living and occupational engagement. The multifactorial nature of falls prevention and management means that referral to an appropriate service to meet the patient’s needs is often required. If someone has lost confidence, has a fear of falling or has problems with mobility or balance, you must consider this in the discharge planning.

Patient information leaflets are available with advice for patients and relatives on Up and about: Taking positive steps to avoid trips and falls - Publications - Public Health Scotland

The effects of medication and number of medications prescribed is a risk factor for falls and falls with harm. Falls are often multifactorial and a holistic approach looking at all contributing factors should include medication history reviewed by medical staff, prescribers or pharmacy staff, to reduce inappropriate prescribing and identify medications that may contribute to falls.

High risk medication

• Antidepressants
• Antipsychotics
• Antiepileptic
• Diuretics
• Opiates
• Sedatives including benzodiazepines
• Antihypertensive after initiation or increasing dose
• Anaesthetic
• Anticholinergics.

 Common side effects

• Orthostatic hypotension
• Balance/gait disturbance
• Drowsiness
• Delirium
• Constipation
• Increased urine output
• Nausea
• Fatigue
• Reduced bone density
• Blurred vision.

See Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029

Continence is a common theme for falls in hospital with many patients attempting to go to the bathroom without assistance. It is important to understand the patients usual level of continence by utilising person centred care and comfort prescribed in relation to need. Consider if the patient can use the nurse call bell for assistance, which may lead to them taking risks with mobility. Bathroom facilities should be offered at each episode of care, especially for patients with cognitive impairment, who are distressed and taking risks with mobility to ensure functional independence where possible.

Patients who have continence related issues must have an appropriate plan in place and be cared for in an area close to bathroom facilities if appropriate/available. 

Bathroom equipment and rails of an appropriate height should be available for patients who require them. Stay in close proximity if the person needs assistance or is known to take risks with their mobility.

Long catheter bags should be avoided, unless using overnight or monitoring urine volumes. Catheter leg bags should be used with straps to reduce the risk of tripping. If patients are catheterised for any reason, it is important to regularly evaluate ongoing need. Some medications may increase the frequency of passing urine, risk of constipation and urinary retention.

The need for supervision while in the bathroom, or on a commode or using bedpans, should be considered for patients who are at increased risk of falls, under higher level supervision, taking risks with mobility, who are unable to use the nurse call bell, have poor sitting balance, visual impairment and less responsive due to the effects of medication and hypoactive delirium.  

It is important to ensure that the patient is supported to have their glasses with them and wear them appropriately, and that spectacles are safe and clean. 

As an ageing population we are seeing an increase in age–related eye conditions such as age-related macular degeneration, cataracts, glaucoma and uncorrected refractive error. These conditions are associated with a decline in visual function and possible visual impairment but can treated and increase patients’ visual ability. Vision plays a key role in balance and posture to be able to stay on our feet. 

NICE clinical guideline NG249 state that a multifactorial assessment should include an assessment of visual impairment.  

There have been “tools” to help inpatient visual function assessments such as:  RCP Look out! Bedside vision check for falls prevention 

Key considerations: 

• Does the patient have any known eye conditions?
• Discuss with a medic if patient complains of double vision (both eyes open), visual field loss or any sudden vision loss.
• Does the patient wear bifocals, varifocals or single vision lenses? If the patient wears glasses for distance (watching TV) ensure they keep them on whilst walking about. If the glasses prescription is not very strong and they are wearing bifocals or varifocals it might be easier to walk about without them. If in doubt the patient should contact their optometrist to advice.
• Ask the patient if they have had an up to date eye examination at their optician?
• If the patient is housebound, do they know they can phone their optometrist for a home visit?
  • once every 2 years if you’re between 16 and 59 years old
  • once a year if you’re under 16, or aged 60 or over.

Postural hypotension, also called orthostatic hypotension, is an abnormal drop in blood pressure (BP) on standing. It can impair quality of life and increase the risk of falls.

Causes can vary and can include:

• Dehydration. Not drinking enough fluids reduces the amount of blood circulating through your blood vessels. This can lower your blood pressure.
• Some heart conditions lead to low blood pressure and prevent your body from pumping blood quickly when you stand up i.e. slow heart rate or heart failure.
• Some hormone problems, such as low thyroid levels or uncontrolled diabetes, make it harder for your body to control blood pressure.
• Some conditions that affect the nervous system, such as Parkinson's disease, make it harder for your body to control blood pressure.
• Anaemia.
• Acute illness and getting up after a prolonged period of bed rest.
• Certain medications i.e. diuretics, anti-hypertensives or for specific conditions such as Parkinson’s disease.

Symptoms can vary and can include:

• Light-headedness
• Dizziness
• Transient loss of consciousness
• Loss of balance and falls
• Visual disturbance.

NHSAA Lying and Standing BP chart should be used to record outcome of lying and standing blood pressure readings.

Lying and standing BP (L/S BP):

See RCP. How to measure lying and standing blood pressure (BP) as part of an assessment to optimise safe activity.

• Explain procedure and ask the patient to lie down for at least 5 minutes then measure and record BP
• Ask the patient to stand, then measure and record BP after 1 minute
• Ask the patient to remain standing, then measure and record BP after 3 minutes
• Record any symptoms experienced by the patient on the L/S BP chart
• If the patient is unable to remain standing, inform medical staff and record this on the lying/standing BP chart
• If no postural drop on 3 separate occasions you can stop measuring, unless requested to continue.

What is a positive result?

• A drop in Systolic BP by 20 mmHg or more with or without symptoms, a drop to below 90 mmHg on standing even if the drop is less than 20 mmHg with or without symptoms.
• A drop in Diastolic BP of 10mmHg with symptoms (clinically less significant than a systolic drop)

Patients should be given a postural hypotension information leaflet.

Post prandial hypotension can occur in 1:3 people over 65 after eating.  This is more common when an individual has diabetes or pre-diabetes.

There are several techniques to help a person cope with the drop in blood pressure and to reduce their chances of falling.  Encourage the person:

• To avoid quick changes in position. When changing from lying to standing, first go from lying to sitting on the edge of the bed, sit for a minute or two and then slowly stand up.
• To circle their ankles and ‘march’ their legs gently before standing up.
• To wait a few seconds before moving, as the dizziness can start in the first few minutes.
• To drink fluids throughout the day, in particular water or decaffeinated drinks.

Falls are not a risk factor for osteoporosis but are a powerful predictor of fracture risk in patients with osteoporosis.

Patients with high risk of osteoporosis such as per SIGN 142 Management of osteoporosis and the prevention of fragility fractures (March 2021)  must be assessed and considered for DEXA Scan and / or bone protection.

The risk factors include:

• previous fracture; parental history of osteoporosis
• history of early menopause (under 45)
• low body mass index (<20 kg/m)
• smoking
• low bone mineral density
• heavy alcohol intake (more than 3.5 units daily) or
• have causative factors from co-existing diseases e.g. diabetes or drug therapy (e.g. long term antidepressants)

Indicators of falls risk:

• weight loss and/or low BMI (at medium or high risk of malnutrition)-indicating the need for good nutritional care
• reduced muscle mass and strength
• low vitamin D status
• dehydration
• hypoglycaemia.

Improvement of nutritional status has been found to reduce falls risk. There is evidence to suggest that ensuring that patients have adequate fluid intake can reduce the risk. Including this within care and comfort rounding will help to reduce the risk of falls.

Key actions

• Assess the nutrition and hydration needs of your patients at risk of falls, ensure they are consuming protein at each meal and after exercise, and you have processes in place to monitor food and fluid intake.
• Initiate nutritional screening, using a validated tool such as the Malnutrition Universal Screening Tool (‘MUST’) in-patient settings, at falls clinics, frailty clinics, after discharge from hospital etc. The ‘MUST’ Toolkit | BAPEN
• Where patients are identified as ‘at risk’ of malnutrition follow guidance and resources including: - dietary advice for patients including how to enrich (fortify) food choices and use nourishing drinks  https://www.malnutritionpathway.co.uk/library/pleaflet_yellow.pdf
• Liaise with your local dietitians to explore the possibility of nutrition education for team members.
• Dehydration can lower blood pressure and cause weakness and dizziness thus increasing the likelihood of falling. Practical strategies to improve fluid intake have been shown to be effective in reducing falls. Ensure to monitor fluid intake and signs of dehydration and actively promote fluid intake, e.g. through documentation and making fluids visible, attractive and accessible.
• Vitamin D supplements: NICE guideline (NG249 2025) states that although there is insufficient evidence to support taking vitamin D supplements specifically to lower the risk of falls, encourage people to follow NHS advice on taking vitamin D to maintain bone and muscle health. Also see the NICE guideline on vitamin D: supplement use in specific population groups. Overview | Vitamin D: supplement use in specific population groups | Guidance | NICE

Hearing and problems with the inner ear can impact on balance. Some individuals may complain of vertigo (a spinning sensation) on head movements; tinnitus (ringing in the ears), instability and unsteadiness (with or without nausea) and dullness of hearing due to vestibular problems. Hearing impairment is associated with many adverse conditions, including social isolation and loneliness, depression, cognitive decline, and poorer physical function. Sometimes dull hearing can be due to a build-up of ear wax.

More than half of older people, above the age of 75 years suffer from hearing impairment. It is important that hearing aids are available, worn and in working order and to consider if the patient can hear and understand instructions. Time should be given when discussing care and treatment and information leaflets issued if available. 

It is important to ensure that the patient is supported to wear their working hearing aid, if applicable.  Batteries can be obtained from the audiology department. Check hearing aid / environment re hearing and consider placement on the ward.

Consider onward referral to audiology if further information or support is required.

Providing higher level supervision within existing resources may require adjustments to staff allocation and workload within the ward to reduce the identified risk. At times, additional staff may be required to support increased ward activity as a consequence of providing essential supervision. Any staffing shortfall should be escalated in line with established escalation processes.

Patients assessed at increased risk of falls should be cared for in an observable area within the ward that is within easy view of staff to maximise supervision or where staff are visible. This may be challenging in single room environments, hence all staff should be aware of most observable areas. Improving staff visibility to patients throughout ward area e.g. nurse based within the room  or, for lower risk patients, the use of observation windows can alleviate patient anxiety and allow easier discussion by patients about their needs. 

Acute and community hospitals utilise three levels of supervision which must be carried out in line with G078 Higher Level Supervision (HLS) Guideline.

Mental health settings utilise three levels of supervision, which should be carried out in line with the Framework for interventions guidelines.

Within acute and community hospitals, two hourly Behaviour Monitoring Charts should be implemented for patients who are at increased risk of falls, who are taking risks with mobility and / or have had a fall to monitor risk taking, patterns of behaviour and as an aid to the level of supervision required.

The frequency of care and comfort should be reflective of the patients greatest need and prescribed one hourly for patients who are taking risks with mobility, unable to use the nurse call bell and under higher level supervision to address needs and as evidence of regular checks.

Consideration must be given, when appropriate, to Technology Enabled Care systems to enhance observation and supervision (out with acute hospitals). 

Unsafe footwear can further compound a falls risk, especially those patients with gait, balance, lower limb and proprioceptive problems. Staff must ensure the patient’s footwear is appropriate, well fitting and encourage them to wear it when mobilising.

Consider anti-slip slipper socks as a short term alternative if the patient has no suitable footwear and use until suitable footwear is available.

Guidance for assessing in-patient footwear

Staff must ensure that patients have safe and comfortable footwear prior to walking or transferring. To achieve this:

• Patients must be encouraged to bring in or have brought in, suitable footwear. It may be helpful to ask family and carers to bring in appropriate footwear (shoes/trainers) if necessary.
• Patients with long term medical foot problems, which cannot be accommodated by ‘off the shelf’ foot wear, must have an appliance request form completed, requesting an assessment by the Orthotist for suitable footwear.

Consider the following questions:

• Does the patient have their own slippers or shoes?
• Do they appear to fit?
• Can the patient put on their own footwear?
• Is the footwear in good condition e.g. not worn down or flattened and are all fastenings, laces in good order?
• Is the footwear likely to require to be washed and if so does the patient have alternative suitable footwear?
• If they have dressings on their feet or oedema does this prevent them from wearing commercially available shoes or slippers?
• Does the patient’s footwear contribute to their instability?
• Where the patient refuses to provide or to wear appropriate footwear or clothing this should be stated in the patients care plan.
• Readiness to change may impact on an individual’s falls risk where some patients will not accept advice regarding risk factors for falls (this can be related to the person’s mental state, impaired capacity or judgement of risk)

Foot health

To maintain/regain mobility, independence and prevention of falls, consideration must be given to condition of feet. Any open wound to the foot should be referred immediately to NHS podiatry. If nails are neglected or the presence of corns/callus may be contributing to a falls risk, it may be beneficial to use a file over these areas and apply an emollient. 

Staff can participate in basic foot care awareness training for Nurses Presentation supported by Podiatry.

Ensure clothing hazards are minimal; this can be reduced by not wearing clothing that is too big or loose or clothing that trails on the floor. Liaise with family, relatives and/or carers regarding bringing appropriate clothing in from the patient’s home, as required. Where possible patients should be encouraged to wear their own clothing.

Care and Comfort Rounds

Regular observation as assessed by professional judgement and checks on patients to fulfil and evidence the delivery of fundamental care – checking if patients are comfortable, offering the use of the bathroom, and ensuring they feel supported and have everything they need within reach may also have the potential to reduce the risk of falls. The frequency of care and comfort should be prescribed and reviewed by the Registered Nurse in relation to the patient’s greatest need. The falls safety section should be fully completed for all patients, whether highlighted at increased risk or not, at each care interaction. If a patient has a fall in hospital, the frequency of care and comfort should be reviewed. Care and comfort should be prescribed one hourly if the patient is unable to use the nurse call bell. 

Personal possessions:

• Glasses and hearing aids should be available, clean and working.
• Drinks, mobile phones, tissues or other personal possessions should be kept within easy reach.
• The nurse call bell must always be within reach for all patients; if unable to use the nurse call bell, one hourly care and comfort is recommended.
• Catheters, intravenous lines and oxygen tubing secure and not trailing.

Furniture:

• Chairs must be available in a range of heights and types, including riser recliners and appropriate bariatric seating to suit the patient's needs.
• Hoists, slings, stand aids and bariatric equipment should be available at ward level to facilitate early mobilisation and rehabilitation and minimise unnecessary risks of remaining in bed.
  • Beds must be kept at the correct height for safe standing for mobile patients; when delivering care variable bed height can be used, but must be lowered after care is completed.
• Some pressure relieving mattresses elevate the bed height, so must only be used for pressure area prevention or treatment.
• If using a low bed provided with mats then follow instructions on how to manage any ‘crash mats’ provided with these beds to avoid creating a trip hazard.
• Brakes must always be applied to beds and wheeled chairs/commodes.
• Placement of patient/furniture to avoid unnecessary clutter around the room.

Low level beds – have many of the same features as a standard hospital bed, but can be lowered much closer to floor level, depending on the manufacturer.

A low level bed should only be used as part of a falls prevention assessment and action plan, and not as a standalone intervention. The patient should still be able to access their personal belongings and nurse call bell.   

Low level beds should be considered for patients who:

• Are at risk of falling from the bed e.g. due to a previous history of falling from the bed, poor bed mobility, uncontrolled movements, atypical anatomy, poor balance, reduced strength or range of movement and impaired cognition.
• Have a significant fear of falling from the bed that is impacting on their quality of life or rehabilitation.
• Are not suitable for bed rails due to risk of entrapment or injury or, risk of climbing over or around bed rails.

Low level beds should not normally be used with patients who are independently mobile, as this will restrict their mobility

How should low level bed be used?

Low level beds should be used at their lowest level whilst the patient is using the bed for sleeping or resting. If there is a specific reason why the bed is not being used at its lowest height this should be carefully risk assessed and documented e.g. small in stature and need to use a lower height bed to facilitate their transfers.

Low level beds should be raised to a safe working height for manual handling and personal care purposes.

How should the use of low level beds be communicated?

The use of a low level beds should be discussed with the multi-disciplinary team and form part of the falls risk assessment and/or bed rails risk assessment. A discussion should take place with the patient and their family/next of kin if appropriate. The use of a low level bed should form part of the patient’s care plan, and should be discussed at hand overs and recorded on the ward safety brief.

Positioning of low level beds

Because of the associated risk factors of patients using low level beds, they should be positioned in the most observable position. If the bed is being positioning against a wall, the risk of entrapment between the bed and the wall, or the risk of accidental injury on the wall must be carefully risk assessed via bedrail risk assessment and guideline.

Risk of injury

Although using a low level bed at its lowest height will reduce the risk of injury, it does not eliminate the risk of injury entirely. Patients are at risk of injuring themselves on other nearby hard surfaces such as furniture, radiators, pipes and the floor or wall. All falls from a low level bed should be treated as a fall, following the same post falls care plan and Datix process.

Low level bed posters should be on display in all wards. 

Bedrails - may reduce the risk of a person accidentally slipping or sliding falling or rolling out of bed, however they may also increase the risk of someone falling if that person tries to climb over or around them.

Bed rails must only be used after a considered individual risk assessment using the Bed Rails Risk Assessment and decision making tool in line with Safe use of bed rails – adult in-patient settings.

Mobilising – walking aids at the correct height and type, must be well maintained and kept within easy reach.

Clutter and trip hazards - Regular environmental checks/walks must be carried out around the ward area and patients rooms to reduce clutter and other trip hazards.

Signposting - Ensure bathrooms are easy to find with signage suitable for those with visual impairment, cognitive problems, or language barriers.

Lighting – must be adequate and even, avoiding glare where possible.

Flooring – must be nonslip with prompt cleaning of spillages. Flooring must avoid patterns that create the illusion of slopes or steps for people with visual impairment and proprioceptive problems.

Technology Enabled Care (TEC) - A wide variety of technology enabled care (TEC) equipment is becoming increasingly available, although not used within the acute hospitals - Movement alarms (bed or chair monitor alarms) are designed to detect patient movement and alert staff with an audible buzzer or via a pager bleep.

Bed and bedside chair pressure sensors as a single intervention strategy do not reduce in-patient bedside falls; however, alarms may be useful in multifaceted approaches to reduce inpatient falls.

Not all TEC is suitable for all people and some may be counterproductive for some patients. Individual assessment and choice of equipment must be undertaken prior to any TEC being used.

Housekeeping - on the ward housekeeping is extremely important particularly to promote an active ward. Staff must ensure that areas are clear, clutter free and any slippages cleared as soon as possible.