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

1. Care Home Risk Factors

Care homes are part of wider communities and when prevalence is high in the surrounding locality then the care home or care homes within that geography are also highly susceptible to COVID-19 entering. The shared environment of a care home and number of residents (especially in older peoples care homes) with underlying health conditions/cognitive decline and often towards end of their life, make the setting at risk of transmission and impact of COVID-19 and other pathogens. Such factors, especially in the context of these settings being people's homes, also make it challenging to control transmission with measures such as limiting movement and implementing isolation. There is also a balance to consider in taking measures to prevent the spread of a virus and the impact on mental health and wellbeing of what is people's own homes.

The RCA report and wider literature also indicated high occupancy^[3] in care homes is associated with high infection rates. This created a particularly challenging situation as care home occupancy needs to be high in order for them to be commercially viable.

1.1 It is important to recognise that any care home, irrespective of size or number of residents, is vulnerable to outbreaks, and prevention strategies at care home level and HSCP level should take account of this.

Progress

Enhanced local oversight support for the care home sector from NHS Boards, Local Authorities and Health and Social Care Partnerships (HSCPs) was set up from May 2020. The Winter Plan 2020/21^[4] sought to strengthen oversight arrangements by asking that daily huddles continued and that proactive monitoring was taking place using the information reported in the Safety Huddle Tool (SHT).

To support care homes the Scottish Government provided funding to Executive Nurse Directors to provide collaborative oversight and assurance which was extended to March 2023. The use of funding has varied across localities, however has included clinical insight and access to expert advice on infection prevention and control.

The Scottish Government led a Short Life Working Group (SLWG) to review oversight arrangements to understand how good practice can be built upon to facilitate improvement across the sector. The work has now concluded and in December 2022 the Scottish Government published a letter and advice note^[5] recommending the continuation of the whole system multidisciplinary support arrangements for care home.

Timely access to clear and concise guidance remains critical for care homes and ARHAI and PHS has been responsible for ensuring guidance is up to date throughout the pandemic. Care homes have previously raised concerns with the changes to guidance and associated delays and alignment of release of guidance from various sources. The CI supports the care home sector with enquiries and interpretation of rapidly changing guidance and developed a Compendium which enabled services to access guidance in one document with most relevant first.

To nationally enable local prevention strategies, PHS collaborated with ARHAI to create a Care home COVID-19 Outbreak checklist^[6] which was published in April 2022. This provides; the definition of a COVID-19 outbreak; how many cases are considered to be an outbreak; information on declaring an outbreak; Standard Infection Prevention and Control Precautions (SICPs) for all residents and Transmission Based Precautions (TBPs) for managing known/ suspected cases.

The CI also published updated Care Homes for Adults - The Design Guide^[7] guidance for new homes in 2022. This was done to ensure learning from COVID was used to inform the future design of care homes and was extensively consulted on. The guide links the size of care homes, quality of care and an association with outbreaks of COVID-19; it recommends that new care homes for older people should have no more than 60 residents with small self-contained units which support cohorting if required as part of TBP and to ensure better IPC outcomes. This guidance was shared with the sector and Health and Social Care Partnerships (HSCPs) via provider updates and on the corporate website/Hub. The Quality Framework^[8] for care homes has been updated to reflect the learning from COVID and includes a specific Quality Indicator about IPC detailed in Section 7

Recommendations:

1.2 A campaign of awareness-raising amongst Care Home staff of particular symptoms in older people should be undertaken

Progress

Reminding people of how individual behaviours can have an impact on the spread of COVID-19 has been a critical part of population level messaging since the onset of the pandemic. Equally, for the workforce it was recognised there needed to be targeted messaging on the importance of certain measures to prevent spread.

The CI supported the care home sector by sharing information on their "provider update," established a specific COVID-19 response team and an enquiry line to manage and resolve individual concerns, questions or complaints. They also developed a COVID-19 compendium to assist services to find the most up to date guidance from PHS and Scottish Government. Information was also sent directly to care services communications for ease of access. Service feedback was positive that it enabled them to use the right guidance at a time of rapid change. CI regularly filtered constantly changing healthcare guidance on behalf of care homes and kept the sector informed of the continuous updates to enable them to limit the spread of infection in care homes. In response to feedback from the sector, COVID guidance was tailored to the care sector

The Implementation of good IPC practice was assessed during scrutiny and assurance activity and complaint visits. Reports were published^[9] after every inspection to identify good practice and areas for improvement. Please refer to Appendix 3 for data about complaints and inspections completed for Care Homes for Adults/Older People, 2020/21, 2021/22 and 2022/23 to 31 August 22. More details on IPC are detailed in Section 7

Going forward

• There should be greater clarity and transparency on commissioning of guidance related to IPC (including testing) and national local partners are able to give timely and responsive advice on social care.
• The Scottish Government will work with policy areas across Government and stakeholders to ensure that there is alignment with publication of guidance from various sources.