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

7. IPC Indicators

The report indicated that IPC practices were not necessarily embedded in care homes and there is a need to ensure that IPC and in particular Standard Infection Control Precautions (SICPs), including hand hygiene, should be employed for every resident, every time as the first line of defence to prevent transmissions of any infection.

Furthermore the scale up required to Transmission Based Precautions (TBPs) needed in the context of a single case, and at pace was a key challenge, particularly for those homes with no experience of an outbreak in the first COVID-19 wave. As a result, the RCA provided a series of recommendations around monitoring IPC indicators, embedding SICPs in every day practice and the use of TURAS to understand safe staffing, escalation and IPC standards.

Recommendations:

7.1 IPC indicators (such as hand hygiene compliance) should be routinely monitored in care homes and comparative reporting over time developed – TURAS should be considered for further development to encompass this

7.2 Monitoring systems for IPC quality improvement in care homes should be further developed

7.3 Further work is required to develop SICPs as part of day to day practice in care homes settings

7.4 The TURAS dashboard should be used by care home managers and by HSCP in order to provide assurance in relation to safe staffing, escalation and IPC

Progress

Indicators:

Health Care Improvement Scotland (HIS) published IPC standards in May 2022 for health and social care settings which superseded HIS's 2015 HAI standards. With the aim of supporting efforts to reduce the risk of infections, these standards support: organisations to quality assure their IPC practice and approaches, and the IPC principles set out in the National Infection Prevention and Control Manual^[19]. The standards are expected to be adhered to across all health and social care settings including NHS Scotland settings, independent healthcare and adult social care including care homes. The CI and Healthcare Improvement Scotland take these into account during all relevant scrutiny and regulatory activities. All other health (including independent healthcare) and adult social care organisations and settings (including adult day care) are encouraged to adopt the standards as good practice.

Monitoring:

Standard 4 relates to assurance and monitoring systemsrequiring organisations to use robust assurance and monitoring systems to ensure there is a co-ordinated and rapid response to reduce the risk of infections and to drive continuous quality improvement in IPC.

The SHT was initially used as a monitoring tool for IPC, but as the RCA report found self-reports tended to show 100% IPC compliance before and during the outbreak which contradicted the findings from CI, inspections and complaints investigations, and HIS reviews. There is a likely need for training and a greater need for monitoring systems of IPC in care homes.

As noted above, during the COVID-19 pandemic the CI introduced an additional key question to the Quality framework^[20] for care homes for adults and older people Key question 7 focused on 'how good is our care and support during the COVID-19 pandemic?'. This key question is no longer a part of the framework, however the quality indicator 1.5, 'People's health and wellbeing benefits from safe infection prevention and control practices and procedures ' has been implemented for scrutiny and assurance activities. QI 1.5 takes account of the Care Home Infection Prevention and Control Manual (CHIPCM) published in May 2021^[21]. It puts IPC at the centre of our work in care homes with all interventions. It is a self-evaluation framework and the CI have provided a self-evaluation and tools for the sector to assess their own performance against the quality indicator which is based on the standards and other good practice guidance.

Standard Infection Control Precautions (SICPs):

SICPs are the basic infection prevention and control measures necessary to reduce the risk of transmission of infectious agent from both recognised and unrecognised sources of infection.

The CI has led IPC standards learning events to reinforce the need to embed SICPs into everyday practice including monitoring and QA of staff practice. The CI promote and signpost to the NES SIPCEP resources. Learning events included representatives from adult care homes, adult day care, housing support services and care at home services to promote the use of SICPs in social care practice.

The CI promotes the Preventing infection in Social Care Settings pocket book ^[22] for use in social care - Preventing Infection in Social Care Settings (including community, care home and homely settings) and the foundation SICEP level at all IPC webinars internal and external

Policy and standard operating IPC procedure guidance was developed and published by the CI to support/inform new applicants of the CI 's expectation around what is required in relation to IPC precautions and practice, before registration is granted.

The National Infection Prevention and Control Manual^[23] (NIPCM) and the Care Home Infection Prevention and Control Manual^[24] (CH IPCM) provide more details on SICPs and TBPs to be applied depending on the route of infection. Until the publication of the National Infection Prevention and Control Manual (NIPCM) for older people and adult care homes in May 2021, a link to the NIPCM was provided on the CI website. Information was also sent to every individual care home and care at home service. A Q&A guide was produced for services to support the use of SICPs.

To support the provision of IPC, education, training and support, in relation to care home and care at home settings. NES and SSSC have been asked by the Scottish Government to work in partnership to provide educational and training solutions to support care home and care at home staff to deliver safe and person –centred care in respect to infection prevention and control (IPC). Reflecting the recommendations from the RCA report the work comprises:

• 1. Development of a mandatory induction module for IPC, in partnership between SSSC and NES, should be undertaken as soon as is practicably possible.
• 2. Consider a supportive education model where care homes educators' roles are developed to support every care home in Scotland.
• 3. Workforce development needs for IPC requires to be considered for all staff in care homes and those providing IPC support to this sector

The IPC advisory group will inform, design and deliver the induction module with the following proposals:

• To extend the reach of the existing SIPCEP 5 Foundation Layer modules and IPC pocketbook to ensure they have relevance for care at home and housing support staff as well as care home staff.
• To create resources that are mobile accessible to ensure parity of accessibility across the sector based upon the content of 5 Foundation level SIPCEP modules and the IPC pocketbook

The induction module will be the first part of the Foundation Layer of the Scottish Infection Prevention and Control Education pathway and will be made available as a NES/SSSC badged mobile enabled learning resource available from both NES^[25] and SSSC^[26] websites.

Safety Huddle tool / TURAS / Health and Social Care Partnerships (HSCP) oversight

With respect to monitoring , TURAS has allowed care home managers to identify care needs and staffing levels to be able to deliver safe and effective care. This has then supported local Care Home Clinical and Professional Oversight teams to provide support where required and if necessary escalate issues to the CI and Scottish Government, and ultimately if required, to use emergency powers held by Ministers.

As noted above the SHT is being reviewed with some questions already having been removed or changed but there is further work to do to review the questions to ensure that there are fit for purpose

Going forward

• There will be a continuing need for further training and support for care homes to adopt and sustain robust IPC monitoring as per HIS IPC standards - standard 4
• Given the high turnover of social care staff, it will be important for organisations supporting care homes to continue to promote and embed SICPs for example through promoting the NES SIPCEP resources.
• Enhancement of staff access to development opportunities such as webinars and learning events, peer support networks providing time and appropriate IT equipment.