CQC Falls Documentation: What Care Home Managers Actually Need to Show

Ask most care home managers what CQC inspectors want on falls, and the answer is usually "a risk assessment." That's true, but incomplete, and it's the gap between having a risk assessment and being able to evidence what was done with it that tends to catch homes out at inspection.

Falls sit under the Safe quality statement in CQC's current assessment framework. The question inspectors are actually working through isn't whether a form exists on file, but whether the service can demonstrate that risk was identified, acted on, and reviewed, and that when something did go wrong, the response was proportionate and the lesson stuck.

What Safe actually requires on falls

Inspectors reviewing falls evidence are typically looking for three things together, not any one in isolation.

The first is an individualised risk assessment, completed on admission and reviewed regularly, that reflects the resident's actual presentation, not a generic tick-box carried over from the last review. A falls risk assessment that hasn't changed in eight months for a resident whose mobility clearly has is a flag, not neutral evidence.

The second is an incident and near-miss log with visible action behind it, not just a record of what happened. If a resident fell twice in the same fortnight and the documentation shows no change in care plan, equipment, or supervision between the two, that's the pattern inspectors are trained to notice. Logging a near miss matters less for the log itself than for what changed afterwards.

The third is evidence that issues don't recur unaddressed. This is where training records, supervision notes, and care plan updates all need to line up with the incident log. A home that can show a resident had a fall, the care plan was updated, staff were briefed at handover, and no further falls occurred is telling a much stronger story than one that can only produce the incident form.

Where NICE's 2025 update raises the bar

NICE published a significant update to its falls guidance in April 2025 (NG249, replacing the 2013 CG161), and it changes what a defensible risk assessment should look like. The headline shift is that NICE now recommends against relying on falls-risk prediction tools or scoring systems to decide who's at risk, and instead recommends a comprehensive, multifactorial assessment for anyone who has fallen in the last year or meets specific risk criteria: living with frailty, unable to get up unaided after a fall, or two or more falls in the past twelve months.

For care homes, this is a practical documentation point as much as a clinical one. A generic scored checklist that hasn't been updated to reflect current guidance is increasingly hard to defend as current best practice if an inspector asks about it directly. Falls documentation reviewed and refreshed against NG249 is a straightforward way to show the service keeps pace with national guidance, not just its own internal process.

Where documentation usually falls down in practice

In our experience working alongside care home teams, the gap is rarely a lack of paperwork; it's usually one of three things: risk assessments that are completed but not meaningfully reviewed after a change in condition, incident logs that record the event but not the resulting action, or staff training that happened once, a while ago, with no refresher tied to actual incidents in the home. None of these are complicated to fix. They just need a consistent owner and a routine, rather than a scramble before inspection.

Turning documentation into practice, not paperwork

The strongest falls evidence a home can produce is a visible, working cycle of assessment, action, and review, repeated, not a folder. That's most credible when it's backed by external clinical input that can speak to individual residents' presentation directly, not just staff filling in a form in isolation.

SteadyMotion Clinical's Falls Shield Protocol builds CQC-aligned documentation into every Clinic Day: structured risk assessment, staff training framed as clinical education, and outcome reporting that gives care homes a clear paper trail between what was identified and what was done about it.

Want a second pair of eyes on your falls documentation before your next inspection?

SteadyMotion Clinical offers a free 30-minute Falls Prevention Seminar for East London care home teams, covering the current CQC and NICE expectations in plain terms. Email hello@steadymotionclinical.co.uk to book a seminar or a Clinic Day.