As part of the Trust's clinical governance arrangements and to facilitate a systematic approach to clinical governance a risk assessment was conducted. This assessment identified that falls were a significant risk of patients, both during episodes of in-patient care and in their own homes. There is little evidence nationally to guide good practice; therefore a multidisciplinary steering group was set up to develop a comprehensive approach to falls prevention. This resulted in the development of evidence based falls prediction tools, Trust policy and guidelines and extensive staff training programmes. Information leaflets have been provided to patients and additional services such as falls groups have been developed.