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A falls prevention programme was effective in care homes in the 3 to 6 months after it was introduced. Researchers say the programme, which was developed in partnership with care home staff, is likely to be cost-effective. However, its effect may have declined after 6 months.

The programme, called Action Falls, takes a systematic approach to listing falls risks and completing actions to prevent them. It is made up of a decision support tool, staff training, a manual and a poster, an App and online training films.

Researchers compared the programme to usual care in care homes. They found that the programme reduced falls in care homes, but its effect declined with time. Regular refresher sessions are needed to maintain staff's awareness of the programme, they say.

The researchers are now implementing the programme in 60 more care homes.

More information about preventing falls is available on the NHS website.

What’s the issue?

Falls are common in older people, and 1 in 2 of those over 80 years fall at least once per year. Falls are the most common cause of emergency hospital admission, and people may lose confidence and independence afterwards.

People living in care homes are 3 times more likely to fall than those living at home. They are also older, more frail, and more likely to have limited mobility than people living in the community. This group is especially vulnerable to the impact of falls.

UK guidelines to prevent falls include the National Falls Prevention Coordination Group recommendations to reduce risk throughout life. The National Institute for Health and Care Excellence (NICE) recommends assessing falls risk and intervening to reduce risk. Neither of these guidelines are specifically intended for care homes.

The Action Falls programme was formerly known as Guide to Action Care Homes. It was developed by researchers working jointly with care home staff, clinicians, the public, voluntary and social care organisations. The content is based on NICE guidelines for falls prevention. It combines 1 hour of care home staff training with a decision support tool listing risk factors for falls, and actions to prevent them.

The Action Falls programme includes the React to Falls app, which contains tools and actions and is freely available to download. Care home staff can refer to the advice when working across the care home.

What’s new?

The study included 84 care homes in England. Almost half (39) used the Action Falls programme and the others (45) practised usual care. Of the 1657 care home residents who participated, most (68%) were female, and their average age was 85 years.

NHS falls leads (a nurse, physiotherapist or occupational therapist with specialist training in falls prevention and bone health) delivered Action Falls training. Care home staff received a 1 hour session at the start of the study. They were trained to assess residents’ risk of falling and to produce a falls reduction care plan . Care homes were provided with a reference manual, a tool to record assessments and care plans, and a poster containing information about falls.

The research team predicted that the impact of the programme would be greatest at months 3 - 6. They looked at the number of falls per resident before, during and after this time point. They also looked at how the programme was implemented, and whether it provided value for money (cost-effectiveness). They compared the number of falls in homes using the programme, with those offering usual care.

The programme:

  • was associated with 43% fewer falls in months 3 - 6 compared with usual care (2 falls per resident per year on average in the programme group, versus 4 falls per resident per year in the usual care group)
  • was associated with fewer falls between the start of the study and month 3
  • lost impact over months 6 to 12
  • was likely to be cost-effective
  • did not reduce the physical activity levels or independence of residents
  • was valued by relatives and care home staff, who appreciated the training, strategies and specialist peer support they received.

The programme was less effective in care homes with less flexible job roles which did not allow staff to prioritise falls management. It was least effective in homes registered as dementia specialist homes. Staff felt that falls were unavoidable in these residents, and that there could be less value in using the programme.

Why is this important?

Before this study there was no practical evidence that a falls reduction strategy could reduce falls in care homes. The team has shown that the Action Falls programme reduced falls in care homes and is likely to be cost-effective.

The researchers stress that the programme did not reduce residents’ physical activity levels or independence. Reductions in falls should not be achieved through practices that limit movement or reduce quality of life.

The programme designated one member of staff in each care home a ‘falls champion’. This person sought to involve all members of staff, including caretaker, chef and cleaners, in preventing falls. The programme might therefore bring changes to staff roles and responsibilities, making falls a priority for more staff members.

After 6 months, the programme lost impact and did not reduce falls compared with usual care. It could be that the programme was not embedded into usual routines. Frequent changes of staff, and the need for regular input to retain interest may have led to a drop in awareness of the programme. The researchers offered refresher sessions at 4 months, but care homes did not often schedule them.

The team is exploring how to improve the impact of the programme over the longer term, including by providing refresher sessions.

What’s next?

The researchers say that their findings should be put into practice as widely and swiftly as possible. Action Falls, or similar programmes, should become part of usual care in care homes, they say.

The team is rolling out the programme nationally, beginning with an implementation study involving 60 more care homes. A further 100 care homes have expressed interest. The programme’s dedicated website allows care homes to download an app, which gives information about falls risks and actions that can minimise them.

The researchers are working on ways to make training more widely accessible. They would also like to explore how the programme can be better tailored for residents living with dementia.

You may be interested to read

This Alert is based on: Logan PA, and others. A multidomain decision support tool to prevent falls in older people: the FinCH cluster RCT. Health Technology Assessment 2022;26:9

The Enabling Research in Care Homes (ENRICH) programme, set up to encourage research within care homes since people living in them tend to have greater risk of ill health and falls.

The cost-effectiveness analysis of the React to Falls programme: Logan PA, and others. Multifactorial falls prevention programme compared with usual care in UK care homes for older people: multicentre cluster randomised controlled trial with economic evaluation. BMJ 2021:375:e066991

Funding: This project was funded by the NIHR Health Technology Assessment programme.

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: NIHR Alerts are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that views expressed in NIHR Alerts are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care.

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Study author

Action Falls is a practical, cheap and cost-effective intervention that can reduce falls among care home residents. We would like UK guidelines and reviews of research (such as Cochrane reviews) to reflect our findings.

We found that it was important to empower staff to feel they could help prevent falls. Staff could carry out most of the actions suggested by the programme themselves. For example, making sure lights are easy to turn on, or keeping residents well hydrated. We asked staff to keep a diary of falls to see if they could spot patterns. Some people might be more likely to fall at a particular time of day, for instance.

Pip Logan, Professor of Rehabilitation Research and Occupational Therapist, University of Nottingham

Chartered Society of Physiotherapy

“Falls are very common in people aged 65 or over, and impact on physical and emotional wellbeing. They can result in injuries (such as broken bones) reductions in balance confidence, social participation, and quality of life and, in some cases, death.

This study targeted people in care settings (a group who are more likely to fall and be injured if they fall) and tested whether a programme (Action Falls) which included identification and mitigation of falls risk factors and provision of education and resources to staff, could influence falls rate.

This study yielded promising results, showing a reduction in falls rate over the first six months in sites that received the intervention, and that the intervention was cost effective to deliver. However, falls reductions were not sustained beyond six months, and inconsistencies in implementation success were noted between different care homes.

Implementation issues were identified and future plans to implement this intervention could consider how to increase the value of this intervention to staff and provide ongoing training support to care staff over time. Additional considerations could include further highlighting the key role physiotherapists can play in reducing falls risk by improving strength, co-ordination and balance.”

Matt Liston, Head of Research and Development, Chartered Society of Physiotherapy


The programme reduced falls in care homes without restricting residents’ activity levels or increasing their dependency. This should be enough to make people think about implementing the programme.

However, the study only included care homes with no system in place for recording falls. So the findings relate to care homes without a such a system. Care homes with a nationally directed falls prevention system that identify residents as high, medium or low risk fallers were reluctant to change to an individualised problem based approach, unless it was adopted nationally by their parent organisation.

There is a tradition to having NHS staff as falls champions. Care home work needs to be recognised and protected in staff job plans. In my community team, no member of staff (including the falls lead) has care home falls work in their job description or job plan. This report provides the evidence for raising the issue with commissioners.

Care home staff need training to increase their awareness of falls, and to identify and manage the risks for individual residents. This research demonstrated the need for ongoing support, without which existing systems in care homes re-emerged as the normal way of working.  Support needs to be prioritised and reinforced.

Sally-Ann Belward, Falls Clinical Lead Physiotherapist, Solent NHS Trust, Southampton

This reviewer was Falls Lead for Solent NHS Trust during the study period but was unaware of the study.

Member of the public

I was concerned that the effect of the programme waned after 6 months. The authors said this may be because some staff did not embed the programme in their usual practice routines and awareness levels may have dropped.

This programme would be effective in an ideal situation, but low numbers of staff will reduce its success. Repeated training sessions will be needed because of the high turnover of care home staff, and this could be a drain on NHS Falls staff.

Carol Munt, NHS Leadership Academy Experience of Care Partner, Tunbridge Wells, Kent

National Care Association

“This has been an invaluable study which considered the importance of prevention as the key to the wellbeing of vulnerable people at risk in care setting. The impact of a fall can be devastating even if the injury is minor as it will affect the confidence of the individual at the very least; whilst major trauma carries substantial physical and mental health risks.

The recommendations of the research are simple and not onerous as creating a ‘falls champion’ keep the issue at the forefront of our workforces’ hearts and minds and the training recommendations will only build on their extensive knowledge and skills. The evidence provided through this research has been attained through care provider participation which makes it more pertinent for colleagues in the sector. National Care Association has been delighted to have been involved in the research.”

Nadra Ahmed OBE, Chair, National Care Association

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