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

14. Built Environment Issues

Maintenance of clean and hygienic areas wit in the built environment in adult care homes is essential in the prevention of the spread of infectious diseases^[54]. The RCA found that environmental factors were an important consideration in the ability of homes to limit disease transmission. As a result, the extent to which homes were able to fully incorporate guidance in relation to social distancing, PPE storage and availability, separation/ isolation and staff cohorting was variable and dependent on the design of the home. Additionally, challenges around design, ergonomics, communal spaces, corridor width and shared shower and bathing facilities, together with the complex nature of the residents' conditions, made the provision of effective isolation challenging.

Many care homes accommodate frail, older residents, some with additional and increasingly complex needs, including those living with dementia and. Staff therefore needed to balance the harms of infection with the need to keep an individual's environment familiar to them as well as support residents who 'walked with purpose'. As a result, the RCA highlighted the importance of understanding local context and the need to adapt the built environment in a risk based and proportionate way. Recommendations, based on findings at four registered services, were therefore made around specialist IPC support for care homes for built environment issues and risk assessment coupled with risk assessment around consideration of fire and falls in context of the built environment to ensure no unintended consequences.

With regards to ventilation the RCA report noted that ventilation should be considered as a control measure in care homes . UK SAGE^[55] (September 2020) published the role of ventilation in controlling transmission of COVID-19, noting its importance, especially during winter. In the intervening period adaptation of spaces for circulation of fresh air has been high priority in mitigating the risks of transmission and featured in national campaigns and guidance.

Recommendations:

14.1 Infection prevention and control specialist support for individual care homes is required when considering the built environment and risk assessment.

14.2 Risk assessment inclusive of advice relating to the built environment covering areas such as fire and falls is required, to ensure that no unintended consequences of changes in the built environment due to IPC measures, are present.

Progress

The built environment covers all aspects of IPC associated with the construction and adaptation of health and care buildings, as well as the design and provision of care in these settings.

In order to support care homes successfully adopt and implement IPC measures, the NIPCM, and context specific Care Home IPCM has been co-produced with national and local stakeholders. The manual has been developed and produced by ARHAI and this includes a link to the care home cleaning specification which was produced by Health Facilities Scotland to coincide the publication of the CHIPCM.

Throughout the pandemic the guidance produced by PHS and ARHAI evolved to reflect the evidence and epidemiology available and incorporated the hierarchy of controls to be used to assess any care setting. This was to ensure that aspects of the care environment were considered in terms of any COVID infection transmission risk. Appendix 18 - Hierarchy of controls^[56] Ventilation was added to the guidance as a part of this in May 2022.

Consideration of the environment is included in the Health and Social Care Standards^[57]. Standard 5.22 states: "I experience an environment that is well looked after with clean, tidy and well-maintained premises, furnishings and equipment" and 4.11 states: "I experience high quality care and support based on relevant evidence, guidance and best practice.

As noted earlier HIS published "IPC Standards for health and adult Social care settings"^[58] in May 2022, where Standard 8 of the publication address the built environment in a standard statement "The organisation ensures that infection risks associated with the health and care built environment are minimised".

In brief, the standards focus on

• organisations taking actions to minimise the risk of infection across all areas of the environment in line with a. Statutory legislation and regulations and b. national guidance processes.
• Communication channels for exchanging information
• IPC risks associated with construction, renovation, maintenance and repair
• Cleanliness of the environment, robust regular monitoring and reporting in line with national guidance
• Staff having access to information, specialist guidance and support with clear understanding of their roles and responsibilities
• Learning from incidents, outbreaks and building and maintenance projects and sharing lessons learned across organisation and sectors to support continuous quality improvement in IPC.

As noted above, the CI Care Homes for Adults – The Design Guide^[59]was published May 2022. This highlights what is expected in designing or refurbishing a building or registering a premises of prospective care home providers when providing a care home service. Prior to the publication of the 'design guide' the CI had in place 'Building Better Care Home guidance'.

It recognises that to enable infections to be reduced, IPC must be an integral part of the planning and design stages of a new-build or refurbishment project with input continues up to the final build stage. This must include arrangements for cleaning once the care home is operational. The guidance signposts a range of resources to support planning and decisions around new builds/ refurbishments. This includes guidance and best practice resources developed for health facilities but which are relevant to residential settings. Importantly the Design Guide recommends that a fire risk assessment should be undertaken at the same time so that measures to assist with IPC do not impede fire safety measures within the building.

14.3 Ventilation guidance should be considered nationally to share general principles to mitigate transmission risks re aerosols over the winter months in care homes

Progress

Good ventilation in indoor spaces can reduce the risk of SARS-CoV-2 transmission. Advice on measures to support good ventilation in care homes is now outlined in PHS COVID-19 guidance, The latest information for ventilation guidance was published in Sept 2022 in COVID-19 - information and guidance for social, community and residential care settings (including care homes for older people registered with the CI)^[60] providing guidance for residential care settings and care homes, focused on ventilation in various areas of the care home setting and links to provide steps in improving ventilation in general workplace^[61] as well as advice to keep room temperature to at least 18⁰C in accordance with UKHSA COVID-19 ventilation of indoor spaces guidance.

The Scottish Government has developed guidance for employers on improving ventilation and the supply of fresh air into the workplace. Coronavirus (COVID-19): ventilation in the workplace^[62]. While not specifically aimed at social care settings, the guidance is relevant as it includes advice on assessing requirements, types of ventilation – natural and mechanical - and the role of air cleaning technologies.

The CI have implemented adult and children's care home design guides^[63]. They take account of the Health and Social Care Standards (as amended 2022) and take account of learning from COVID-19

TURAS Learn have a dedicated page "Protecting yourself and your workplace environment^[64] - Unit C – COVID-19: helping you in your role: Protecting your workplace", one of the multi-professional skill bundles developed for any health care practitioner working in any setting who may be caring for people with COVID-19. They are provided to use in conjunction with other resources from NES or from their own health board. They provide resources to support staff with infection prevention and control and proper use of PPE when caring for suspected or confirmed cases of COVID-19.

14.4 Consider extension of the whistleblowing service to all staff across the health and care sectors.

Complaints and whistleblowing:

Whistleblowing is an act of staff or ex-staff raising concern about wrongdoing at work. Under the Public Interest Disclosure Act, to be considered whistleblowing, the allegation must be in the public interest and the worker must believe that one of more of the following has occurred:

• a criminal offence
• someone's health and safety is in danger
• risk or actual damage to the environment
• a miscarriage of justice
• the company is breaking the law
• someone is covering up wrongdoing.

Under the Public Interest Disclosure Act, every registered care home must operate a complaint procedure so that people can make their complaint directly to a service. This legislation underpins the CI work and all services have a statutory duty to have a complaints policy and procedure in place. The CI has a complaints function as the regulator for social care and social work and people can also make complaints directly to them. Complaints to the CI are managed through complaint pathways. The CI provides information on their website about complaints and whistleblowing and their complaint procedure.

The RCA report highlighted that two care homes out of the four that were reviewed, had complaints made either from a family member or staff in areas of care environment, IPC and staffing issues.

During the pandemic the CI put additional processes in place to manage complaints this included enhanced triage of complaints by inspectors and escalation pathways to obtain support for services for example supply of PPE from PPE hubs. Where complaints were received about services these were risk assessed, discussed with oversight groups including DPH to gather full information and agreement needed on addressing concerns. Where the CI did investigate this was undertaken as a full covid inspection and outcomes shared with all partners.

As part of its complaint procedure and duties the CI has in place whistleblowing procedures that inform staff of their rights and protection. Employees can raise issues of concern (whistleblowing disclosures) in confidence or anonymously with the CI about services that are registered.

Progress

The CI have duties as a third-party prescribed person under the the Public Interest Disclosure (Prescribed Persons) Order 2014, which means an employee or former employee can make an internal or external whistleblowing disclosure to the CI. It has in place robust whistleblowing policies that enable staff making complaints to the CI of their right and protection under the legislation. Most whistleblowing complaints received by the CI comes via the complaints team and as a prescribed body under the Public Interest Disclosure Act, the CI is required to publish and annual report on complaints from staff that are considered whistleblowing. This Act provides protection to workers that make disclosures in the public interest.

The Prescribed Persons Order 2014 sets out a list of over 60 organisations and individuals that a worker may approach outside their workplace to report suspected or known wrongdoing. The organisations and individuals on the list have usually been designated as prescribed persons because they have an authoritative or oversight relationship with their sector, often as a regulatory body. An up-to-date list can be found at Whistleblowing: list of prescribed people and bodies under social care section^[65].

The CI, HIS and SPSO^[66] have whistleblowing duties and the three regulators have held joint whistleblowing workshops. In addition all Health and Social Care Partnerships and NHS boards have whistleblowing policies in place.

Unison also published a whistleblowing guidance and model policy^[67] in July 2022 which can be used by staff from all public service organisations.

SSSC regulate people working in social services to make sure that there is confidence that staff have the right skills, values and training to do the job. In March 2022 SSSC updated their fitness of practise threshold to provide more clarity for anyone who like to raise a concern if they believe that a worker is not fit for practise or impaired who are registered with them or a student applying to register with SSSC. Details to raise a concern can be accessed from their website.

The SSSC and the CI published raising concerns in the workplace guidance^[68] for social service workers, social work students and employers (2019). Recognising that every social service worker has a professional duty to take action to raise any concerns they have about the care, dignity and safety of people who use services, the guidance was developed to support staff to raise concerns. The guidance explains the difference between raising a concern and whistleblowing and when a person raising a concern qualifies for legal protection under whistleblowing law.

Going forward

• Consideration should be given to further advice on ventilation for social care settings for example by adapting the Scottish Government's guidance for employers on improving ventilation and the supply of fresh air into the workplace, taking account the availability of other guidance e.g. the Health and Safety Executive

Consideration should be given to the emerging evidence base around use of systems to support monitoring of ventilation in settings.