Template Action Plan Time & Date Location of Witness/1st on Name of resident of Fall fall scene Injury Received Action Plan Reason for fall (Refer Action Taken (Refer Referral to Risk Review to Green column Action (Refer to to Orange column Lilac column Assessment undertaken pathway) Blue column pathway) pathway) pathway) Review (Date) (Date) Full Name Signed .......……… ……………………………………….. Designation Knowsley Care Homes only. ……………………………………..
Template Action Plan Name of resident Time & Date of Fall Location of fall Witness/1st on scene Injury Received Reason for fall (Refer to Green column pathway) Action (Refer to Blue column pathway) Action Taken (Refer to Orange column pathway) Referral to Lilac column pathway) Risk Assessment Review (Date) Action Plan Review undertaken (Date) Full Name ……………………………………….. Signed .......……… Designation …………………………………….. Knowsley Care Homes only.
Criteria-for-reporting-a-Safeguarding-Concern-Knowsley-Guidance-V3-March-2017.docx