Coronavirus (COVID-19): care home outbreaks - root cause analysis

7. IPC indicators

Lack of time, heavy workload, ratio of registered nursing staff, and lack of facilities are frequently indicated as barriers to IPC adherence being optimised in all health and care settings^[17]. All of these issues were found to be present, to a greater or lesser extent, in each of the four homes. PPE availability had previously been an issue earlier in the year during the first wave, however we did not hear this as a current issue in any of the homes we talked to. There was a local issue in one care home with availability of visors in recent weeks, however this was reported as resolved locally and with the support of Scottish Care. 

The pandemic is now illuminating that IPC requires to be embedded in ways of working in a context-specific way in each care home. This means local 'adapt to adopt' approaches to implementation of guidance. The care homes we spoke to recognised that guidance developed nationally, or at board and care home group level, could only give high level principles and that there was 'no one size fits all settings', due to the care context, differences in built environment design and the facilities available. Whilst in the first surge in cases of the pandemic there was little evidence of standard infection control precautions (SICPS) being embedded in day to day practice in care homes, this review heard that the scale up required to transmission based precautions (TBPs) needed in the context of a single case, and at pace is the key challenge currently. This is a key focus needed for those homes with no experience of an outbreak in the first COVID-19 wave, as their preparedness was not previously challenged. 

Of particular concern is the reporting in TURAS safety huddle data of high IPC compliance in these homes, in some cases at 100% before and during the outbreak was reported. These data are self-reported by the care home manager and do not reflect the findings from care inspectorate/HIS reviews, which indicated a lack of compliance with IPC during the current outbreak period that inspections had been done within. There is a likely need for training and a greater need for monitoring systems of IPC in care homes. 

In two of the homes we spoke to, it was very clear that infection control was considered in the context of winter viruses such as norovirus and flu, as these are the most common IPC challenges faced by care homes each winter. One home described this as 'an outbreak box to open when you have norovirus to remind you what to do'. We also heard about the pandemic revealing that 'hand hygiene practice needed to be improved as it was discovered that this was not being done in line with current guidance'; these are indicators that IPC was not already well embedded in these homes. IPC and in particular SICPS, including hand hygiene, are the ten elements that should be employed for every resident, every time – they apply in all care settings and at all times. SICPS are the first line of defence to prevent transmissions of any infection.

Recommendations:

• 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
• Monitoring systems for IPC compliance in care homes should be further developed 
• Further work is required to develop SICPS as part of day to day practice in care homes settings
• The TURAS dashboard needs to be used by care home managers and by HSCP in order to provide assurance in relation to safe staffing, escalation and IPC