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

2. First Wave

The RCA report highlighted the range of lessons that were learned from the first wave of the pandemic. These included structural factors such as the time to mobilise resources and support by national and local partners as well as specific sector challenges such as staffing, pay and conditions, and availability of PPE. However the issues facing the four care homes that formed part of the RCA were different to that of wave one. During wave two, challenges related to continuing awareness and vigilance, including but not limited to IPC training; physical distancing; car sharing; and understanding or managing risk that arises outside of the direct care environments, for example staff returning from holiday in parts of the UK/abroad where there is high prevalence.

Another difference noted by the RCA was that outbreaks in the second wave were reportedly occurring more frequently (80%) in those care homes not impacted in the first half of the year. None of the four care homes that formed part of the RCA previously had an outbreak. The report noted that aside from the finding from studies in the earlier wave that care home size was linked to higher rates of suspected cases, care homes could be 'virus naïve' as they had not had an outbreak in the first wave and so may not have had the same level of preparedness and vigilance around on-going risk; wider use of PPE and variation in IPC adherence may be impacting transmission in specific homes, especially given the risk of asymptomatic spread.

Recognising the international evidence that once COVID-19 has been introduced into a care home it has the potential to result in high attack, the report set out a series of recommendations with the aim of supporting care homes to adopt active measures to prevent the introduction of COVID-19.

Recommendations:

2.1 Board level and national-level lessons learned for care homes are required to be continuously reported and shared in the pandemic with the care homes and the wider system.

The RCA found little collation of any formalised wider system learning reports from the first wave and subsequently. Therefore, given the changing issues facing care homes and the importance of active measures to prevent introduction of COVID-19, this recommendation was made to ensure a continuous cycle of whole system learning at both local and national level.

Progress

As reported in the previous section, the enhanced local oversight support for care homes established in May 2020, which has evolved over time, has been helpful. As well as supporting the sector in relation to IPC procedures, PPE use, and translation of guidance, a range of mechanisms were put in place at local level to share learning both at individual and regional care home level. Regional level opportunities included care home forums / networks to bring staff together to discuss current challenges, learning from outbreaks, update to date guidance etc.; and the CI worked with oversight teams to support implementation of guidance in registered care services.

Nationally, a number of initiatives were developed to firstly understand the impact and challenges of COVID-19 in care homes and secondly to share that information/learning and critically respond where needed. The former focused on up to date good quality data and information and the second various cross-sector forums where issues could be discussed, experience shared and solutions developed.

At the start of the pandemic, there was no single source of timely quality and safety information/data for care homes. Specific recommendations on data and digital were made separately in the RCA, but the foundation for this recommendation under first wave and so many others is ensuring that there is robust evidence base to guide local and national discussion and response.

To support national understanding of key issues for care homes, the Scottish Government asked the Directors of Public Health (DPHs) across Scotland to complete a weekly return on key information relating to the sector from May 2020. The returns reflected the judgement of DPHs on the basis of the totality of assurance data including HSCP and CI data. DPHs identified a RAG status for care homes on the following areas: the level of COVID-19 suspected or confirmed; knowledge and adequacy of IPC measures; staffing position; an overall assessment of the RAG rating of all homes. The reports were used to inform local and national thinking and action planning to help the sector and were shared with the CI .

In August 2020 the Scottish Government, in collaboration with care homes, the Scottish Care and the Scottish Social Services Council, developed the 'safety huddle tool' (SHT) for the care home sector, hosted on the TURAS platform. The premise of SHTs are well researched and established in the health sector and are critical to continuous improvement^[10]. The SHT was designed to collect pertinent data such as IPC measures, occupancy, staffing and outbreak levels to enable situational awareness and risk assessment for care homes. As recognised in the Independent Review of Adult Social Care to support timely escalation and early intervention where appropriate. However, the SHT is completed by care homes, and places a considerable administrative burden on them during the height of pandemic. There are also ongoing questions over data quality and completeness. Ensuring data quality by design and ways to minimise reporting burden for data collection needs to be considered as part of the lessons learned from implementing new data systems.

The CI completed lessons learned from COVID this brought together intelligence from inspections and complaints carried out. The CEO wrote to the sector to outline areas for improvement identified through scrutiny and assurance activity (8 October 2020) and provided links to good practice documents to support services. They developed winter plans incorporating lessons learned and provided webinars and guidance for the sector. This included specific information about IPC and wellbeing. The CI also developed and implemented two winter plans that included lessons learned and used webinars to guide and support the sector.

The CI also updated their inspection framework^[11] to take account of learning from the pandemic which included developing and publishing quality illustrations of very good IPC practice and weak practice. From May 2020, Key Question 7 was used to support services this was incorporated into the full self-evaluation framework. The Inspectorate used the IPC Addendum and Care Home Infection Prevention and Control Manual (CHIPCM) as a key line of enquiry at inspection from September 2021.

A short life working group (SLWG) was established to devise and develop IPC standards, promoted HIS IPC standards from the publication in May 2022 along with developing, planning and leading on learning events about the new standards and provided learning to all adult care homes over the summer months of 2022.

The National Outbreak Management (NMT) team met weekly during the peak pandemic period, and the data was shared with local Health Protection Teams (HPT) provided by care homes on a weekly basis to support sharing of lessons learned nationally and locally. HPTs worked with Care Homes with outbreaks throughout the pandemic and they were often in daily contact with the care home with an outbreak, who would provide their daily figures to the HPT. This was reduced to monthly basis when the cases were low.

The Care Home Rapid Action Group (CHRAG) was set up weekly from May 2020 as a whole system group to urgently consider the impact and response of the pandemic in care homes. The group comprised of Government, Local Government, NHS, HSCP, Scottish Care, Coalition of Care and Support Providers in Scotland (CCPS), SSSC, Health Improvement Scotland, BMA and RCN. This was replaced by the Pandemic Response Adult Social Care Group (PRASCG) which met on a twice weekly/then weekly basis from September 2020. This had an expanded remit to continue to consider wider social care pandemic challenges beyond care homes.

The GOLD command adult social care group, comprising national and local partners, met regularly to firstly to consider the impact of the pandemic in the sector and secondly to consider the need for national and local responses.

The Clinical and Professional Advisory Group (CPAG) was established by Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) at the start of the pandemic to provide clinical and professional advice and guidance for protecting the care home sector during COVID-19. Initially focused on care homes, it was then expanded to adult social care. The group, which has supported the development of guidance throughout the pandemic, brought together clinicians and external stakeholders including care home providers, NHS, CI, SSSC and Local Authority. The group considered a number of the RCA recommendations in their agenda. The last meeting of CPAG took place in December 2022.

2.2 All long-term care facilities (care homes, residential settings and community hospitals) need to implement active measures to prevent introduction of COVID- 19 and be kept up to date with the emerging epidemiology and IPC issues.

The recommendation refers to the timely and effective introduction/adoption of guidance in what was a fast moving environment where understanding around the epidemiology of the virus was rapidly evolving. Comment was made in the RCA report about the challenges staff had in keeping up to date with the latest guidance which was being updated on a regular basis.

Progress

The CI developed the COVID-19 compendium of guidance for social care. This combined all guidance sources into a single resource for care services. This included guidance on PPE, laundry, IPC, visiting, health and wellbeing. It enabled services to access easily the most up to date links to Covid-19 guidance developed by Scottish Government, PHS, ARHAI, SSSC and social care overarching bodies.

This was designed to support ease of access to current guidance and to support the sector who expressed concern about the volume of changes to guidance. The COVID-19 compendium was a 'one stop shop' for COVID-19 guidance in social care. This initiative ended in September 2021 and was replaced with promoting the Scottish Government COVID-19 information platform for social care.

CPAG considered ways to ensure COVID-19 guidance was streamlined and communicated in an engaging and effective way. As part of this the Scottish Government undertook work to understand staff feedback about national guidance from a range of organisations . This resulted in changes to the issuing guidance for example not issuing updates on Fridays, ensuring that any updates were identified at the top of guidance. PHS has streamlined its COVID-19 guidance for social care settings with the publication of social, community and residential care (SCRC) settings guidance which now incorporates adult and older adult care homes. There is still work to do to streamline COVID-19 guidance – face mask, public health and IPC guidance is developed by different bodies for example, PHS and AHRAI and Scottish Government resulting in different publications. However there is considerable coordination between organisations and the PHS COVID-19 guidance for social care settings now contains all advice.

2.3 Additional factors found for consideration of further guidance and support include: travel associated risks in care workers, on-going variation in care homes with respect to glove use, hand hygiene, and cleaning.

The wider lessons learned from other population-level COVID-19 outbreaks, such as shared coach travel and holidays in areas of high prevalence of COVID-19 within and outside of the UK underpinned this recommendation. This aimed to ensure that the workforce understood the risks associated with certain individual/group behaviours and the resulting impact on the spread of infection. In particular, it was considered that care home managers should manage the risk by ensuring uptake of staff testing remains high and is undertaken in a timely manner.

Progress

Messaging on the prevention of key risks was to care homes directly and reinforced by local public health teams, NHS Boards and Health and Social Care Partnerships (HSCPs). As discussed above, the CI actively undertook considerable activity to share resources and guidance designed to guide and support the workforce on risk factors.

This activity included the CI's COVID-19 Flexible Response team (CFRT) running two workshops for Nurse Agencies in February 2022, highlighting key guidance to reduce the spread of transmission and supporting good practice. In addition, the SSSC supported CI to make resources available to non-registered social care staffing agencies.

In October 2021, the CI , Scottish Government and ARHAI Scotland delivered IPC workshops about IPC good practice, to health and care staff who provide support and care in adult care homes. Consistent practice was the focus of learning which also included exploration of the built environment as a homely rather than clinical setting.

The CI developed, planned and led other learning events to the sector about the implementation of the HIS IPC standards between June and August 2022.

The Healthcare Framework for Adults living in Care Homes: My Health, My Care, My Home (would be referred as Health Framework in this document) (June 2022) also included a recommendation about the implementation of the HIS IPC standards.

2.4 IPC, inclusive of its application to visiting, is critical to the sector. Care homes should have access to expert IPC advice to support local risk assessment and a mechanism should be developed to enable sharing of what works well, in terms of applying the national guidance in a local context.

The aim of this recommendation was to ensure that where needed care homes would have access to local level IPC advice and support.

As outlined above there was local wrap around enhanced support for care homes from Health Boards and Health and Social Care Partnerships who were able to provide oversight and assurance in a collaborative manner. As part of this, Nurse Directors were asked to be provide support in a range of ways including: being accountable for the provision of nursing leadership support and guidance; support for clinical input with effective community arrangements in place; providing support and oversight of IPC in care homes; and identify and support sourcing of staffing. This has continued throughout the pandemic and evolved over time. As noted above the arrangements for the oversight teams including the nurse director role has been reviewed and confirmed for 2022/24.

The CI in addition to the activity described above provided an advice line for registered services, their staff and members of the public to support understanding and application of guidance. They published Q&A for services and direct support to managers. They worked closely with Directors of Public Health (DPH) teams to support services in understanding the need for risk assessment and application of policy. When IPC concerns were raised or observed during scrutiny and assurance activity, the CI worked with partners to ensure the necessary steps were taken by care homes to address concerns.

Going forward

• The Scottish Government need to ensure the purpose of the SHT on quality and safety is achieved and we work with the care home sector, and other key stakeholders, to realign the focus of the tool towards improvement.
• In doing so national local partners need to support care homes and the sector to realise the benefits of robust quality and safety information.
• National local partners need to actively continue to address the data reporting burden on care homes to ensure that information is reported once but shared when needed multiple times.
• As highlighted in section 1 we need to continue to ensure there is transparent, timely and easy to access guidance for the sector in relation to COVID-19 but also other infectious pathogens.
• Work should continue on streamlining and where possible aligning IPC guidance for social care settings
• The national local partners need to ensure care homes have the confidence to continue to implement the relevant IPC guidance in a local context.
• The Scottish Government will continue to review collaborative improvement partnership with the sector
• The CI will continue to advise individual services about ways to reduce infection risk while maintaining connections between residents and their relatives. For example, by providing information about how visits could be safely managed and providing practical assistance to connect digitally.
• The CI will continue to work with the Scottish Government and relative groups in preparation for the introduction of Anne's Law that will protect people's rights.