Action 2. Training for applicable staff should be relevant to their role and include, where appropriate, the risks and operation of these devices, the provision of training to carers/patients, reporting issues, servicing and maintenance and risk assessments. A safety consultant had previously identified that 14 beds needed bed rail extensions to prevent the occupants falling out of bed. But the provider had not authorised the work until after the resident’s accident. There have been other serious incidents involving bed rails reported to the Medicines and Healthcare Products Regulatory Agency (MHRA). Does the manufacturer/supplier provide any information on special considerations or contra-indications?

Implement maintenance and servicing schedules for the devices in the inventory/database, in line with the manufacturer’s instructions for use and/or service manual. Prioritise devices which have not had regular maintenance and servicing. If this is outsourced, compliance with the schedule should be monitored. Bed rails, also known as side rails or cot sides, are widely used to reduce the risk of falls. Although not suitable for everyone, they can be very effective when used with the right bed, in the right way, for the right person. The resident can become trapped between the bottom of the rail and the mattress if the gap beneath the rail is too large.When bed rails are used during the course of a work activity, such as in a care home or hospital, the employer or self-employed person providing them must ensure that they are safe However, accident data shows that bed rails sometimes don't prevent falls and can introduce other risks. Does the benefit of any special or extra mattress outweigh any increased entrapment risk by the bed rails created by extra compression at the mattress edge? Other risk factors (such as inappropriate use or incompatibility) are included in the MHRA’s updated guidance on the management and safe use of bed rails and should be considered as part of an appropriate risk assessment. An example risk assessment is provided in Appendix 1 of the guidance. Assessment of appropriate bed rails should be routinely incorporated in the clinical assessment of all patients. Can you use ‘crash mats’? Please do not use crash mats for people who are dying or who does not move in bed instead use bed rails.

These measures helped demonstrate that the provider had carried out sufficient improvements. Therefore, the inspectors rated the ‘safe’ question as good. What can you do to avoid this happening? When something goes wrong in health and social care, the people affected and staff often say, "I don’t want this to happen to anyone else." These 'Learning from safety incidents' resources are designed to do just that. Each one briefly describes a critical issue - what happened, what CQC and the provider have done about it, and the steps you can take to avoid it happening in your service.According to investigations, deaths were found to involve factors including inadequate risk assessment, maintenance issues and children and adults of small stature using beds which are designed for use by adults with typical body dimensions. We are delighted to tell you that the NRS Healthcare EasyFit Plus+ Bed Rail has been tried and tested by our team of Occupational Therapists who are proud to give it the OT Recommended seal of approval. trapping between the bedrail and mattress, headboard or other parts because of poor bedrail positioning.