Coronavirus (COVID-19): Route Map - supporting evidence for the 22 September 2020 review

WHO criterion 3: Outbreak risks are minimized in high vulnerability settings, such as long-term care facilities (i.e. nursing homes, rehabilitative and mental health centres) and congregate settings.

Hospital Associated Infections (HAI)

Since 1 July, Public Health Scotland (PHS) has published weekly validated nosocomial COVID-19 hospital onset data.

At the start of May, the Scottish COVID-19 Nosocomial Advisory Group was established with its main focus on analysing and interpreting existing nosocomial data. Based on their work, recommendations and the updated 4 UK nations IPC guidance, additional measures to reduce in-hospital transmission of COVID-19 have been developed:

• Physical distancing of 2 metres is standard practice in all health and care settings;
• Asymptomatic healthcare staff testing for COVID-19 was expanded from testing all staff working in an area where there is an outbreak of COVID-19 in a non-COVID ward, to include healthcare staff working in specialist oncology wards, long term care of the elderly wards, and long term care wards in mental health facilities.
• On 18 September guidance was issued on extended use of Fluid Resistant (Type IIR) Surgical Masks covering primary care and wider community care and community hospitals.
• The guidance recommends staff providing direct care to individuals should wear a Fluid Resistant (Type IIR) Surgical Mask at all times throughout their shift and non-clinical staff members should also wear a Fluid Resistant (Type IIR) Surgical Mask if they need to enter an area where direct care is undertaken
• It recommends that anyone visiting or attending these settings also wear a face mask/covering.

NHS Boards are integrating infection prevention and control into their remobilisation plans. Health Boards are ensuring the effectiveness of their remobilisation plans regarding additional cleaning, good hand hygiene, ventilation, physical distancing, low, medium and high risk pathways for patients and staff movements and rostering.

Prisons

The Scottish Prison Service (SPS) have taken steps to resume regime activity including the resumption of in-person visits on 28 September. A provision for virtual visits will remain to ensure continued family contact for prisoners.

As of 25 September, there are no confirmed cases of COVID-19 in Scottish prisons and 50 individuals self-isolating across 8 establishments.

Care Homes

The Scottish Government has taken regular and firm action to support care homes across Scotland and to protect the wellbeing of those who work and live there. We have established a Care Homes Clinical and Professional Advisory Group sponsored by the Chief Medical Officer (CMO) and Chief Nursing Officer (CNO) to provide up-to-date clinical and professional advice on the response to COVID-19 in the care home sector.

Since 8 June, the UK Social Care Portal has been available for Scottish staff and care homes. We have access to a weekly maximum of 67,900 tests and this is the primary method by which care homes are testing staff. Staff agencies have also been notified that all staff should be tested prior to deployment into a care home and advised that the UK Government Employer referral portal should be used. Care home staff testing will now be carried out by the NHS. This will ensure quicker turnaround times in for care home staff, reduce false positives and enable timeous action where required.

We are introducing visiting in care homes in a staged way. Further visiting options will be introduced incrementally and subject to scientific advice. Information gathered from the safety huddle tool will provide further data to support future changes or to support delaying of such changes.

On 3 September we published a staged plan for the return of services that contribute to the wellbeing of residents in care homes. The first stage being the resumption of routine health and social care visiting from 7 September in care homes that have been COVID-free for 28 days. Those care homes participating in the care worker testing programme have had relevant risk assessments signed off by the local Director of Public Health. Communal activities within care homes will also resume in the same manner, provided the same conditions are met.

Other Vulnerable Settings

The package of measures to minimise infection applies to all adult care homes. We will strengthen information on other residential settings including adult mental health, learning disability, and secure mental health services. We are putting in place location-specific measures across the mental health inpatient estate to minimise the risk of infection.

In terms of secure mental health services, as part of the NHS they are following all Scottish Government and Public Health Scotland guidance. The Minister for Mental Health wrote to NHS Chief Executives to set out the presumption that all patients being admitted to a secure hospital should have a negative test before admission, unless the patient does not consent to a test, lacks the capacity to consent or it is in the clinical interests of the person to be moved urgently and then only after a full risk assessment.

The COVID-19 Children & Families Collective Leadership Group brings senior leaders together to review data on children, young people and families with vulnerabilities, and to identify issues requiring action as we move through and out of the crisis. A children's residential care group, supported by SG officials including clinical advisors, considers necessary advice to that sector.

We are working with the Office of the Chief Social Work Adviser (OCSWA) and other stakeholders to agree a route map guiding the safe continuation, resumption and response to changing needs for people in the community in receipt of social care services. The route map will be driven by a set of overarching principles, based on human rights and support the moving through different stages of recovery from the pandemic.

Day care and stand-alone residential respite services can now reopen in line with the relevant infection protection and control measures and guidance. Support at home and outdoor activities or children's day care can also continue in line with existing infection prevention and control guidance.

Guidance to support the safe re-opening and delivery of building-based day services for adults was published on the 31 August on the Scottish Government website and guidance on stand-alone residential respite/short break facilities is under development to issue as soon as possible. Ministers wrote to the sector on 23 September to confirm guidance to enable safe reopening of stand-alone residential respite for adults and children.

Regarding children's services at community level, agreement has been reached with stakeholders on when incremental steps for targeted and general support might commence, inside and outdoors, and with groups and households.

The route map for social care services is particularly complex and, as a result, services will look different when they reopen; for example, changed staff to service users ratios in day service provision, which will impact on the unit cost of these services.

Personal Protective Equipment (PPE)

The Scottish Government, in partnership with the NHS/NSS, Scottish Enterprise, the National Manufacturing Institute Scotland and private companies, has increased both the volume of PPE being manufactured in Scotland and the amount being imported to provide PPE for both immediate and future needs.

Adding to well-established arrangements in hospitals, all health boards now have a Single Point of Contact (SPOC) to manage local PPE supply and distribution for health and social care. For social care, in both the private and public sectors, the supply of PPE is primarily the responsibility of social care providers themselves. However given the pressure on normal supply chains due to COVID-19, we have committed to providing top-up and emergency provision to ensure staff have what they need.

Other public services, such as the police and fire services, have their own routes of supply, but they are joined up with the Scottish Government Procurement Directorate and, via policy leads, with the PPE Division. We have also established a process with a third party supplier, making PPE available to purchase for organisations providing essential public services if they have difficulty accessing supplies through other means.

Guidance has been produced to ensure that all sectors are aware of the appropriate use of PPE and are using it when required by risk assessment alongside other measures to ensure the safety of staff. The PPE division has developed a PPE Sustainability strategy to ensure the supply of PPE for Phase 3 and longer-term resilience.

Workforce

Steps have been taken to bolster and support the social care workforce. A national online recruitment portal has been developed to support local efforts to enable those with relevant skills and experience to re-join the workforce went live on 29 March.

Emergency Legislation

We have acted quickly to introduce interventions that will protect the progress that we have made so far. The Health Protection (Coronavirus) (Restrictions and Requirements) (Scotland) Regulations 2020 require the mandatory use of face coverings in certain indoor public places, including museums, galleries, community centres and places of worship.

We have brought in new legislative powers to ensure the swiftest intervention if individuals in a care home are being put at risk. The Coronavirus (Scotland) (No. 2) Act 2020 contains powers allowing health boards to issue a direction to a care home during the coronavirus pandemic to take a specific action; ministers to apply for an emergency intervention order in a care home; and puts beyond doubt the powers of health boards and local authorities to voluntarily purchase a care home or (in the case of local authorities only) a care at home service. These powers can be used where there is serious risk to residents' health, life or wellbeing due to Covid-19. and allow the highest risk cases to be addressed urgently.

Care Homes Data

Over the week ending 17 September 37,095 staff were tested. This included 2,161 staff in homes with confirmed COVID -19, and 34,934 staff in homes with no cases of confirmed COVID -19.

As at 23 September, 95 (9%) adult care homes had a current case of suspected COVID-19. This number relates to care homes who notified the Care Inspectorate of at least one suspected case of COVID-19 in the previous 28 days.

There were 9 new positive Covid-19 cases among care home residents for the week of 14-20 September.

National Records of Scotland are the official source of COVID-19 deaths. The most recent publication on 16 September continues to show a steady decrease in the weekly number of deaths in care homes, falling from a peak of 341 at the end of April to 3 deaths from 7 to 13 September.

Cases of infection in hospitals, prisons and care homes have consistently declined since late April to mid-September, although there are some signs of cases starting to increase.

Application of robust testing measures will ensure that infections are contained, and that staff are routinely tested to ensure their health and wellbeing. We will take further action to address nosocomial infection in healthcare settings that is comprehensive and system wide and that delivers sustainably and at pace; and ensure for care homes full compliance with the testing policy in place.

Funding

We have confirmed funding of up to £100 million to address immediate sustainability and financial challenges across social care. We have carried out engagement with a range of stakeholders on spend during 2020/21 and we will make a funding allocation to further recognise cost implications. We will continue to work with the sector to understand the funding required to respond to COVID-19, to support remobilisation of services, and to ensure that patient safety remains the top priority at all times.

In conclusion:

• Cases of infection in hospitals, prisons, care homes and other vulnerable settings have declined from late April to mid-September although there are some signs of cases starting to increase.
• Additional, stringent infection prevention and control measures and guidance to safeguard patients and staff in these settings have been established;
• NHS Boards remobilisation plans core aim is to restart paused services in a safe and clinically prioritised manner;
• Well-managed and established plans are in place to meet demand for PPE;
• Application of robust testing measures will ensure that infections are not being moved around the care system, and that staff are routinely tested to ensure their health and wellbeing;
• Early action to address nosocomial infection in healthcare settings that is comprehensive and system wide is being taken; and
• Significant national and local funding is in place to strengthen resilience.

On the basis of the evidence summarised above the assessment is that Phase 3 criterion continues to be met at this review point.