Care homes in the UK have been at the epicentre of the COVID-19 pandemic. Some estimates suggest up to 40% of homes have experienced an outbreak. Now, in many parts of the UK, care homes are struggling to fill their vacant beds and occupancy rates are tumbling (The Guardian, 26th May 2020). It is not surprising that families are reticent about sending their loved ones to a care home. And, with much of the UK’s workforce being furloughed or laid off, a new army of volunteer carers is helping to reduce the demand for care beds.
This is a huge threat to a sector that is already vulnerable, and presents a major challenge for care providers and managers, on top of those imposed by the COVID-19 Infection Control measures. Some homes which have experienced an outbreak are inevitably suffering from the stigma associated with being one of the 40%, making it harder to attract new residents. In the case of our home, which specialises in dementia care for 22 elderly people, we have been carrying 3 vacant rooms for two months since our outbreak. This current occupancy level of 86% is well below our usual 95%. It will represent a major financial threat if we are not able to attract new residents in the near future. I’m not sure I see much light at the end of this tunnel, but I am encouraged that we, like other care homes, are now better prepared to protect residents than in the past.
Like everyone in the sector, we need help to ensure our home is as safe as it can be if another COVID-19 wave does arrive. Or, indeed, if there are other pandemics in the future. We’ve done our best to demonstrate to relatives of our residents, and those enquiring about space on behalf of others, that we are doing everything within our control to prevent further outbreaks and protect residents and staff. Indeed, having been through an outbreak, we believe the lessons learned are helping us be more prepared than the 60% of care homes who did not have an outbreak. With those lessons in mind, we are making changes to our staffing model and pay levels, and implementing improvements to our facilities to ensure we are able to offer maximum protection.
Yet the media is rife with stories of all the systemic failures leading to very high fatality rates in UK care homes. Reassuring those deciding how to provide the best care for a vulnerable relative is no small order. I have contributed to that picture myself, by highlighting many of the failings at Central and Local Government levels (The Croft Blog, 21st May 2020). But, almost one month on from the end of our own outbreak, it’s time to reflect on whether our home and others are now better prepared to keep residents and staff safe.
My answer to the question posed is in the title of this article is “Yes, I believe it is much safer now for your loved one to come to The Croft. But, there is still more that can be done by those who support the social care sector to help reduce risks further.” Many of the systemic issues associated with funding for the sector (London School of Economics Blog, 28th April 2020) and low-pay levels (The Croft Blog, 5th April 2020), will take years to address. The Government claims to be making a start, and I welcome that. But, more critically, supply chain issues for PPE and Testing during the first peak are also now being resolved. Regular testing for elderly care home residents and staff is, according to Helen Whately, Social Care Minster, imminent as the Government awaits a steer from SAGE on the most effective way to implement this (The Guardian, 11th June 2020).
Access to the £600M of extra funding being made available to care homes through Local Authorities is starting to filter through and is very welcome. We will be using this to improve our sanitising and PPE stations around our home. We are also increasing our staffing levels, so as to avoid having to use agencies in the event of staff availability dipping due to self isolation impacts. Our partnership with our preferred agency staff supplier was one of our success stories during the last peak. But, rightly, we are being encouraged to do all we can to minimise the extent to which staff move between care homes, for Infection Control reasons.
However, more can and should be done. We were recently invited to participate in a virtual debrief of lessons learned during the peak with our Care Quality Commission Inspector, which was a welcomed discussion. Some of our key lessons are being passed back up the chain and will, hopefully, over time, be considered along with all the other themes. However, some of our feedback focused on what we believe is ‘low hanging fruit’ for the Government and the various agencies that support care homes. And I believe fast action is needed to help care homes be better prepared.
First, I ask Government to put aside ego and demonstrate that they are learning from other countries, bringing back their lessons to the rest of us. All too often, we hear ministers say that we still have a lot to learn about this virus and how to handle it. But, it appears other countries have not had anywhere near the care home death rates experienced in the UK. Debates over the accuracy of fatality figures being reported by different countries are a poor excuse for seeking to learn from the experience of others. We need to know what Hong Kong and New Zealand have done differently that has led to much lower care home fatality rates.
One specific example of a lesson the UK Government seems to have overlooked is in the asymptomatic nature of carriers. Helen Whately recently said “we are only now learning about the asymptomatic carriers and their implications for the spread of the virus” or words to that effect. However, my team was warned about the asymptomatic carriers back in March, when we worked with a specialist in infectious disease control, based in Thailand. She responded to a job posting on Indeed for an Infection Control Consultant (Vacancy Ad) and spent a week advising us via Skype on how to prepare for the arrival of the virus. She warned us at that time that we should “act as if the virus is already in the home”, due to the asymptomatic nature of many carriers. She also advised that Thai authorities thought the virus was highly likely to be Airborne, residing in the gasses expelled from a carrier, rather than just droplet-based. Whether the virus is airborne is still being contested by scientists, but we acted as if it were on the basis of ‘better to be safe than sorry.’
This advice, from a PHD qualified nurse practitioner overseeing the COVID-19 response for 22 hospitals in Thailand, was invaluable. Unfortunately, even we were caught off guard. The virus did arrive at The Croft, via an asymptomatic carrier as predicted. This resident had been to a hospital for an outpatient procedure only a couple of weeks prior. When she returned to hospital in April, for a condition which appeared to be unrelated to COVID-19, she tested as positive for the virus on admission. It was at that point we realised we probably had COVID-19 in the home.
Although we were shocked, we were prepared and we believe the advice from our Thai consultant made a significant difference to our ability to contain the virus. Additional measures included: incredibly tight procedures in our kitchen to ensure it did not act as a central point for spreading the virus; disinfecting all deliveries on arrival or isolating them for up to 72 hours if they cannot be disinfected, like fresh vegetables; keeping all PPE in the drawers of specially set-up and easily accessible PPE stations throughout the home so that the PPE itself didn’t become a source of cross-contamination, in the event the virus is airborne; and purchasing plastic sheeting in advance which was used to cover doorways of those who had tested positive, again to help deter the virus from spreading in the event it is airborne.
We believe these measures, combined with the stellar efforts of our team, helped us to contain the virus. In the end, only 4 of our residents tested positive for the virus, with just one tragic fatality – our first case. The others all recovered and, in part, we attribute this to further advice we had received from Thailand. Which was to do all we can to avoid a ‘Viral Load’ impact, whereby the volume of the virus ingested contributes to the severity of its impact. Strict self isolation measures were adhered to for over 2 months at The Croft in order to minimise cross contamination and potential viral loading. These are only just being slightly relaxed now, after all staff and residents have been tested several times, in an effort to moderate the mental health impacts of ongoing self isolation.
Our appeal now to the Government, and to those agencies who support care homes, is to demonstrate they are learning from the experience of other countries, especially those who are more experienced at dealing with highly infectious, often tropical, diseases. In the case of this virus, they were at least a couple of months ahead of us in terms of their experience in trying to contain outbreaks. Their insights, judgement and guidance should, therefore, be invaluable to us all.
Another “quick win” for the Government may not feel like one at first glance. My challenge to ministers is: “Please get joined up in the way you deliver your support for the care sector.” There are a myriad of central and local government agencies which have been offering support to care homes. Everyone from the UK Government, the Department for Health and Social Care, the CQC, Public Health England, our Local Authority Provider Engagement Network, as well as other local agencies, have all been contacting us with advice on how to manage in this crisis, as well as offering much needed resources. However, many of these e-mails and phone calls are actually offering the same things.
This translated into a huge volume of e-mails and phone calls, especially during the height of the peak. The effect on the recipient can best be described as trying to drink from a fire hose. Not only did these represent a distraction from our core task of running a home in a crisis. But, more importantly, the high volume of contact, as much as 20 or 30 long e-mails per day offering new advice and resources, were impossible to stay on top of and things were missed. This information overload was certainly reflected in the various on-line care home Manager and Provider Forums in which we participate. And the main themes of conversations were people asking one another for clarification of various policies and how to access important resources, like additional funding.
It’s clear that the highly fragmented and siloed nature of the support for care homes, across multiple agencies, cannot be re-engineered overnight. Nor does it necessarily need to be. But, single points of contact can be put in place, whose job it is to help care manager and providers navigate all the support, regulatory advice and reporting that is needed during a crisis. Those people could be especially assigned to a group of care homes, much in the way CQC’s Inspectors are now. But their responsibility during a crisis would be to help them navigate the support, acting as a conduit for key information, as well as feeding up lessons and new support needs to decision makers. Ideally, these are people who already exist within the care sector system and know it intimately. My vote would be for CQC Inspectors to perform this role, especially as most inspections were suspended during the first peak. Our Inspector did a valiant job of trying to help us in this capacity anyway.
By sharing lessons from around the world and helping care home managers navigate all of the support available, the care sector can build on the PPE, Testing and Funding improvements which have already happened, and continue to make their homes better equipped to keep people safe during the next peak. And, hopefully, this will help provide the ongoing reassurance needed by relatives that care homes are ready again to properly look after their vulnerable loved ones in the new normal.
And finally, just one last request of Government, please stop saying to the world at large that things are happening to support care homes, when they are clearly not. A loss of credibility as a result of over-promising and under-delivering on PPE and Testing will be the cross you have to bear. For care providers it makes life very difficult when we think we can rely on resources being made available, which are not there after all. We could all have been much better prepared with PPE, for example, if we’d had a more realistic understanding of the time-frames by which the Government provision would possibly be available.
Simon is co-owner and Registered Provider of The Croft Residential Home in Newton Abbot, Devon, as well as owning other small businesses. Prior to returning to his native Devon, Simon spent 20 years living and working in the USA, Europe and Asia advising large global organisations as a Management Consultant on Leadership, Strategy, Culture and Organisation Effectiveness. He is a Fellow of the Royal Society of Arts.