Coronavirus (COVID-19) care home outbreaks - root cause analysis: progress report November 2020 to September 2022

13. Carer Perspectives

COVID-19 led to prolonged periods where adult care home residents and in some other residential settings were unable to receive visitors during lockdowns and local outbreaks. Social connections and meaningful activity are vital for the wellbeing and quality of life of people living in a care home. Families and friends play an essential role in the health and wellbeing of people who live in care homes, in terms of both practical and emotional support.

The RCA report considered visiting policies, guidance and local adoption and highlighted the distress experienced by residents and carers, due to lack of contact. It noted the importance of considering the delicate balance between maintaining a safe environment in relation to footfall, with the clear adverse impact on the mental and physical health of residents who are unable to comprehend the rationale in relation to restrictions.

Variance in local implementation of national visiting guidance by some care homes was highlighted and in some cases resulted in extended closures of care homes to visiting. The importance of support and guidance to care homes from local DPH NHS boards / Health and Social Care Partnerships to ensure that people remain connected to their loved ones was emphasised. As a result recommendations were made around context specific care home guidance or advice in line with national guidance and consideration of the role of visiting champions

The CI's Quality Indicator Framework for use in self-evaluation and inspection includes guidance about the importance of the role that relatives, friends and named person(s) play in the delivery of care.

Recommendations:

13.1 Context specific care home level guidance is required locally, in line with national guidance, for visiting and care practices within the individual home that makes it easy for consistency in application of IPC needs in a risk based and proportionate way to enable compassionate care in a homely setting

13.2 Provision of a 'visiting champion' or other similar arrangement is desirable in ensuring that advice and guidance relevant to specific contexts is readily available and consistently applied

Progress

A staged approach to the return of indoor visiting was initially launched in summer 2020 starting with support for outdoor visiting moving to indoor visiting. The ability of care homes to return to full indoor visiting was challenging due to outbreaks, the emergence of new variants including DELTA and variance in approach across organisations and health boards and the Scottish Government policy. In February 2021 'Open with Care'^[45] supporting meaningful contact in care homes was published which encouraged care homes to return to indoor visiting. Since then Open with Care guidance on visiting has been updated to support and encourage care homes to return to routine and regular visiting within and outwith the home with links to detailed IPC advice from AHRAI and PHS COVID-19 guidance for care homes.

A subgroup of CPAG was formed - Open with Care Oversight Group - comprising Care Home Relatives Scotland, the CI, Directorate for Public Health, Health and Social Care Partnerships and provider representatives to monitor implementation of visiting guidance and provide recommendations for further support and guidance. At the same time a CPAG engagement group met to provide opportunities for family and third sector organisations to provide feedback on visiting. This group was merged with the oversight group in early 2022. The Open with Care oversight group was expanded in late 2021 to encompass legislation on visiting - Anne's Law^[46].

In September 2021 guidance was updated to recommend a 'named' visitor during an COVID-19 outbreak. This guidance was developed in consultation with PHS, the CPAG, Care Home Relatives Scotland and the care home sector. People living in care homes can now choose up to three named visitors to visit them one at a time during an outbreak.

Open with Care visiting guidance was updated in June 2022 to support the continued move to routine and normalised visiting. This included a principles document^[47], a family leaflet^[48] and an easy read^[49].

Throughout the pandemic the CI has advised individual services about ways to reduce infection risk while maintaining important connections between residents and their relatives to ensure people have contact with loved ones when restrictions resulted in closing down care homes to visiting. In March 2020 CI published a guidance on how to support people to stay in touch using technology, The CI, provided practical assistance about how to connect digitally.

The CI supported people to have visits with loved ones at the end of life and where people were experiencing distress symptoms. Early on in the pandemic the CI highlighted the rights of people and included wellbeing and connected to people in the inspection methodology from May 2020 and provided information about how visits could be safely managed. The CI supported the introduction and implementation of Open with Care ensuring that people had contact with people important to them in line with their rights and to support wellbeing. The CI developed and delivered webinars on visiting, sharing good practice and shared a blog by a care home manager on how visits could be safely managed and difference made to people living in the care home.

Building on Open with Care guidance, the Scottish Government utilised powers conferred by Section 50 of the Public Services Reform (Scotland) Act 2010 with the introduction of two new statutory Health and Social Care Standards^[50] on visiting in March 2023. The Health and Social Care Standards set out what people should expect when experiencing health, social care or social work services in Scotland. The CI supported development of these standards and developed guidance for the sector on the implementation of the new standards. The CI in April 2022 published updated Quality Framework^[51] for Care Homes

for adults and older people and they introduced a new quality indicator to support connect and visiting for people taking account of the new standards and the fundamental rights of people to see and be connected to those important to them.

The CI has been commissioned by the Scottish Government to work with the sector to prepare them for implementation of Annes Law. Work is underway with the CI and stakeholders to support and prepare the sector for the introduction of Anne's Law, which has been incorporated into primary legislation as part of the National Care Service (Scotland) Bill^[52] that was published on 21 June 2022. It will allow Scottish Ministers to exercise a power under subsection 2 of the Public Services Reform (Scotland) Act 2010^[53] to require care home service providers to comply with any direction issued by the Ministers. The Directions will set out in more detail how providers are to facilitate visiting and enable residents to maintain contact with the people who are important to them and can be implemented before the National Care Service is established.

While care homes have for the most part adopted 'Open with Care' guidance and the new Health and Social Care Standards, Anne's Law will underpin rights by statute and ensure a consistent approach in the context of any future health threats. The CI Anne's Law project was set up in 2022 to ensure people have the right to see and receive support from those who are important to them. The project team hear directly from people and their relatives.

Regarding the RCA recommendation on visiting champions, many care homes used COVID sustainability funding to employ visiting coordinators to support the practical elements of safe visiting including advice to families, managing footfall within the home, supporting visitor testing etc.

Going forward

• The Scottish Government will continue to work with the Anne's Law and Open with Care Oversight Group alongside the CI, local partners and relatives to monitor visiting in care homes and the adoption of the new H&SC standards, and to prepare the sector for the introduction of Anne's Law.
• The Scottish Government will work with the Anne's Law and Open with Care oversight group to develop visiting Directions to ensure they capture the lessons learned from the COVID-19 pandemic and deliver on Anne's Law.