COVID-19 Care Home Crisis, a Provider’s Perspective

Already in a state of vulnerability, care homes have been hit hard by COVID-19 in the UK.  Their story needs to be told before it’s too late.

Unconstrained by non-disclosure agreements, and unlike NHS staff, Social Care Providers are free to be blunt about their perspectives on why care home residents appear to have succumbed disproportionately to COVID-19 in the UK.  The death rate metrics and international comparisons will be debated for years to come.  However, the fact remains that too many residents and staff have died in care homes.  As a residential care home Provider for only 18 months before the current crisis, I feel compelled to share my perspective on why this is, in an attempt to ensure lessons are learned and applied.  But also, to help prevent the systemic funding issues, which have blighted the sector for decades, from falling off the radar once again and putting care homes at further risk.

The social care sector was systematically privatised over the last 30 years.  Governments believed a private ownership model would be run more efficiently, while allowing for the return on capital that private owners would require.  Although cost effectiveness may have improved, the consensus is that, since privatisation, the sector has been incrementally starved of funds in what is now called the “social care funding crisis”.  Successive Governments have ignored this, kicking it into the long grass and hoping it will go away until the next regime comes along.  Meanwhile, the demographic pressures on social care mount up and reinforce the need for a robust provision.

But care homes and home care agencies have started closing at an alarming rate, and the provision in the sector is shrinking rather than increasing.  Some of the big care home groups could have survived if their shareholders, generally private equity entities, had more modest capital return expectations.  It could be argued that the greedy have fallen first, leaving behind a large number of smaller care homes, and care home groups, all privately owned but with limited resources to weather a protracted storm.

Coupled with this has been the Government’s strategy, delivered through Local Authorities, to look after the elderly and vulnerable in their own homes for as long as possible.  Meaning that care homes are left with the most vulnerable people, often with severe comorbidity health conditions, such as Dementia and Diabetes.

Set against this context, the arrival of the highly infectious and lethal coronavirus to the UK in February represented a significant threat to the sector.  In March, tales of high fatality rates in care homes in Italy, France and Spain heralded an apocalyptic scenario, with bodies piling up and, in the worst cases, Providers walking away and leaving residents to their own devices.  By mid-May, UK care homes have now become the “new front-line for COVID-19” according to commentators, with estimates ranging between 25% to 40% of all COVID fatalities occurring in care homes.

Probing questions, including from the likes of former English Health Secretary Jeremy Hunt, are being asked of the Government as to why the advice to lock down care homes was delayed until the end of March.  Despite lessons from elsewhere in Europe, the Government’s position in mid-March was still that there was “limited to no risk in care homes.”  Ministers had their reasons for this position, which are now somewhat opaque, because they are disputing it was their stance in the first place.  However, based on our own judgement, my co-provider David and I decided the Government was acting too slowly.  On the 15th March, we implemented a lockdown at The Croft, our care home, by closing it to all but essential health visitors in order to protect our 22 residents and staff.

Despite taking this early action, The Croft became one of the first homes in the Newton Abbot area in Devon to have a Confirmed Outbreak of COVID-19.  This was a huge blow, since David and I, with our manager, had been working very hard to establish the most robust Infection Control measures we could possibly implement, including requiring most of our residents to self-isolate in their rooms from the point of lockdown.

We were caught by surprise, as our first resident with COVID-19 had shown no symptoms of the virus.  Doris was admitted to hospital for another health condition overnight on the 18th April.  She was tested on admission for COVID-19 , and we were informed on the 20th April that she had tested Positive for the virus.  Seven days later we received the devastating news that Doris had died in hospital, still completely asymptomatic for the virus, although the cause of death was confirmed as COVID-19.

Until recently, this asymptomatic nature of the virus has been largely unreported.  But from our experience, it is likely to be one of the main reasons the virus has raged through care homes in the UK and Europe.  It’s hard to contain a virus when you don’t know it’s there to begin with, or who has it once it’s arrived in the home.  During our Confirmed Outbreak, we had a total of five people who tested Positive: Four residents and one staff member.  All but one of these cases has been completely asymptomatic for the virus, even when taking into account the full range of symptoms that has been added over the past month or so.

Other reasons why the virus has remained unchecked in care homes relate to the shambolic situation with Personal Protective Equipment (PPE) and Testing availability.  While Ministers take to the lectern and baffle us all with impressive figures, including hundreds of thousands of tests per day and billions of pieces of PPE distributed, the reality is that the focus on these figures is designed to obscure a truth.  Which is that the Government has over-promised and massively under-delivered on these two critical elements in the fight against the virus in care homes.  And this remains another key reason why the virus is still rampaging through homes.

Our own experience in securing PPE is reflective of the broader picture we’ve pieced together from talking to other care home Providers.  In early March, we were told we would receive “all the PPE we needed to contain the virus and protect residents and staff.”  In practice, the Government has done little to supply us with PPE.  Over the last two months, David and I have spent almost £15,000 on PPE, for a small home with 22 residents and 25 staff.  This has all been secured through our own sources by David.  We tried the various Government and Local Government e-mail boxes and contact numbers.  The Local Resilience Forums, often mentioned by Ministers, eventually became our single point of contact for Government supplied PPE.  But we’ve either not been able to get through to the telephone number, or our e-mails have been ignored.

Once we reached Confirmed Outbreak stage, we expected to receive extra support from Public Health England’s (PHE) local Public Health Team (PHT).  We had been told in advance by Government Advice e-mails that the PHT would help by taking over our Infection Control process to ensure the highest standards of containment.  In reality, the South West Public Health Team has done very little for us, other than send a lengthy e-mail with various templates to complete for risk assessments and to confirm the status of our Outbreak.  We’ve received no support with PPE from SW PHT, more the opposite, as they’ve explained that this responsibility lies elsewhere, sending us on a wild goose chase.

To date, we have received only 300 masks from our Local Authority and 200 aprons from our local hospital, secured with the help of our local Community Nursing Team.  In the midst of our Outbreak, the 300 masks and 200 aprons would have lasted less than a day, assuming we were wearing them in line with Government Advice on PPE usage.  Our Outbreak lasted for 23 days.

As well as spending a significant amount of our own time and money in securing the PPE needed to protect our people, a more sinister aspect of this story relates to the ongoing downgrading of PPE protocols.  We’ve closely monitored the Government Advice on what PPE should be used at various stages of an Outbreak.  We’ve done this partly to keep informed in a fluid situation, but also to ensure the PPE we purchase continues to qualify for the refunds being offered to all care Providers for their PPE expenditure.  The Government has made much of the billions of pounds it has pumped into Local Authorities, and one of the ways that money is to be spent is by reimbursing care homes for their PPE costs.  

Mindful of the robust processes normally established for claiming money from the Government, we wanted to ensure we didn’t submit claims for PPE items that wouldn’t qualify for reimbursement, if not on the Government-recommended list.  What we’ve noticed is that the list of PPE that is no longer recommended, is now getting larger.  The cynics within us wonder whether the claim made by a BBC Panorama programme in April, that the Government has deliberately downgraded the status of the virus to match its own inadequate PPE supplies, might well have merit.  

We’ve given up on trying to source the gowns recommended by the World Health Organisation (WHO) for anyone coming into contact with a positive case of COVID-19.  Our own solution within our Infection Control protocols is for 4 aprons to be worn simultaneously to cover the majority of a carer’s body.  Panorama claims that the UK Government downgraded the threat level of the virus, in order to avoid having to recommend gowns they simply didn’t have in stock.  And this was on the back of the lessons from the Government’s own CIGNUS pandemic simulation in 2017, when PPE shortages and the threat to care homes were highlighted as a major risk to be addressed.

What we’ve noticed, along with our health professional partners, is that the downgrading of PPE standards has occurred throughout the last couple of months of the pandemic.  The applications of the three levels of surgical masks has been watered down.  For example, the mid-level FFP2, or N95, masks which were originally recommended for use with COVID-19 Positive Cases, or those with symptoms, are no longer recommended.  They have been replaced by the lowest level Fluid Repellant 3 ply surgical masks.  We can only speculate on the Government’s reasons for doing this, but we have not been prepared to compromise on standards during our own Outbreak, and we have maintained the use of the N95 masks, including issuing them to visiting nurses when they are seeing one of our COVID-19 Positive cases.  If it means we are unable to reclaim these costs as originally promised, then so be it.  We are simply not prepared to compromise on the safety of our staff.

We could cite plenty of other examples like this in relation to PPE.  The dithering for weeks over whether masks should be worn at all times by care staff is another example of the Government’s poor handling of the situation.  Eventually, by mid-April, PHE and our local authority confirmed Government advice that masks should be worn at all times, if carers can’t guarantee to be more than 2 metres away from another resident or staff member at all times.  Anyone who knows anything about the way care homes operate, including the freedom to roam for most residents, would know this policy is laughable.  It has meant that masks have to be worn at all times, which is just as well because many homes, including ours, had implemented that policy well ahead of the Government advice.

In recent weeks, it feels like Ministers are cultivating a new tactic for deflecting blame back to providers for the PPE shortages and risks to life of care staff.  Grant Shapps, Transport Secretary, and others are starting to remind the public that care homes are in private ownership, and it’s “always been the responsibility of Private Providers to secure and pay for their own PPE.”  This unsubtle shift of emphasis is perhaps a desire to exploit the public discontent bubbling up about care providers who have started to pass on additional PPE costs through fees to their self-funding residents, probably because they doubt they’ll qualify for the rebates being offered to homes with Local Authority funded clients.  The original promise that all care homes would be supplied by the Government with all the PPE they need is, potentially, being cast aside in favour of a new story, which shifts accountability for the high death rate of carers back to private Providers. 

However, an even more fertile ground for criticism of the Government relates to the gap between its promises for Testing and the reality on the ground.  Here, frankly, Ministers don’t just look out of touch, they are demonstrating a level of incompetence which is profoundly worrying.  Given the asymptomatic nature of this virus, with people being infectious while showing no COVID-19 symptoms, testing is absolutely essential in care homes.  Yet, even with a Confirmed Outbreak, we have only been able to secure a fraction of the Testing we have been promised by Ministers in the daily COVID-19 Briefings, by working around the systems the Central and Local Government have put in place.

We’ve used our relationships with local health professionals to secure tests for our residents and staff at critical times, rather than going through official channels, which have been so dysfunctional it beggars belief.  To give one example of many: After two weeks of being passed systematically from one Government Agency to another, to secure testing for all of our staff after our confirmed Outbreak was declared, we resorted to asking our staff to sign up individually for tests through the Department of Health and Social Care’s “key worker portal”.  

Several staff were deterred from doing this as the portal was completely out of date at the point it was launched for asymptomatic care workers.  This was because the filtering questions still required that carers only qualify for testing if they had symptoms and were self-isolating.  We had to instruct our staff to lie their way through those filter questions in order to book a test, which they all did, and the tests were conducted over the weekend of 2nd and 3rd May.  Each received a confirmatory text to say results would be sent back between 48 and 72 hours.  Two weeks later, over 11 of our 23 staff had still not received the result of their tests, and it was only on Friday 15th May that most received a text to say their tests were inconclusive and they needed to re-organise another test!

Prior to this particular debacle, I had been trying to secure batch testing for our staff, through the various vehicles suggested to us for this purpose.  The SW Public Health Team said the CQC was responsible for offering staff testing.  The CQC initially pointed us back to our Local Authority, who thought they had a route to batch testing, but then realised this had been moved back to the CQC.  Eventually the CQC explained that Public Health England was organising staff testing.  On contacting them, PHE then pointed us in the direction of a new portal that had been launched by the Department for Health and Social Care, specifically designed for care homes wanting to order testing kits which would be sent to each care home in need.  I dutifully followed the guidelines and ordered 50 tests for all of our residents and staff, including agency workers.  Seven days later, I received a confirmatory e-mail apologising for the delay in dispatch of the “0” number of tests I had ordered and asking me to be patient.  You really couldn’t make this stuff up!

This whole process of being bounced from pillar to post and eventually ordering 50 tests has so far taken over two weeks to navigate.  I came to describe it to those in the Government agencies who were trying to guide me through it as “Endless Helter Skelters within a Labyrinth”.  This description seemed to resonate with many of the very good people who were really trying to help.  But they will never be allowed to comment on all of this for fear of losing their jobs.

Don’t be fooled by the Ministers when they try to impress you with all the figures on testing capacity, and unconditional and immediate support for care homes.  They are either out of touch or, more likely, just not listening to those of us who are trying to tell them what is really going on with testing in care homes.  At the moment, we still don’t have enough access to tests at The Croft, which we feel we need in order to ensure we don’t succumb to another Outbreak.  Like others, we feel a rolling programme of weekly testing is needed as a minimum, to help us cope with this highly infectious and largely invisible virus.

Having spent a twenty year career consulting with large global corporations and small businesses on leadership, strategy, culture and organisation effectiveness, I’m acutely aware of how leaders are prone to pulling the easy levers that affect change, rather than addressing the meaty cultural, or systemic, dysfunctions.  It is much easier to throw capital at an issue, or restructure people, than unpick and redesign systems and processes that have to operate through a distributed network of sub-organisations.  Perhaps this is why rapid progress was made with the creation of the Nightingale Hospitals, while fixing testing and PPE supply cannot be done quickly to compensate for a lack of preparation.  By throwing money at the Nightingale Hospitals, the Government has been able to rapidly compensate for the relatively low levels of ICU capacity in the UK, compared to other European Countries.  It’s just a shame that this spare capacity hasn’t been needed.

That focus on the Nightingale Hospitals was entirely understandable, given the scenes of chaos which came to us from Italy and Spain in the weeks before the virus arrived in the UK.  But it is not appropriate for Ministers to use this success as an excuse for not being able to deliver the PPE and Testing needed by care homes.  Throwing capital at a problem is a relatively easy thing to do.  Understanding how to deliver support through highly siloed Government agencies with subservient cultures, where honesty is rarely spoken to leaders, is a much bigger challenge that has tripped up the Government and, I believe, caused a death rate among care home residents and carers that could have been avoided with more skilled and grounded leadership.

In the past week, the Government has made more promises to care home providers.  In theory, £600M has been pumped into Local Authorities to support social care by beefing up our Infection Control mechanisms.  But, by the weekend, it’s still not clear what that actually means.  There has been talk of bolstering care home staffing, reflecting the issues many of us have had with keeping up our staffing levels during the pandemic.

If that is the case, and it can be delivered in a meaningful and timely way, then it will be very welcome.  Staffing is a huge challenge in the sector generally, and in particular during the pandemic.  In our own case, we have lost a handful of staff members who have chosen in favour of protecting their young families, or a vulnerable adult who lives with them.  This, in addition to having a number of staff at any one time requiring to self-isolate with symptoms.

We’ve done our best to bolster our staff ranks by agreeing a deal with our preferred agency staffing partner to access a small team of staff who are trained in our infection control measures, and will only work with us.  However, as our staff return from isolation, we are less able to honour this agency contract, and are having to recruit more staff instead.

This is proving difficult, despite the Government’s advertising campaign to promote work as a carer, and we are currently experiencing a shortage of applicants for our vacant roles.  At the root of this problem is the degree to which carer roles are simply undervalued and under remunerated.  Most care staff earn less than the Real Living Wage and struggle to make ends meet.  As a result, it tends to attract people who have other responsibilities, like looking after dependent children or vulnerable adults, and who try to fit the job around delivering those roles.  Or, those who work full-time in care often have to augment their income with other jobs, or work unreasonable hours, to make ends meet.

This position of low pay levels for carers is not sustainable.  If we want our elderly and vulnerable to be looked after properly, then we, as a society, will have to start paying for it.  Probably through our taxes.  How many people in the UK realise that we have one of the lowest total tax burdens of all countries in Europe, at about 35% of GDP?  France at 45% of GDP and Germany at 40% put us to shame in terms of the size of their welfare state.  Heartwarming stories like Captain, now Colonel, Tom, raising over £30M in funding for the NHS, simply plaster over the cracks of a broken Health and Social Care Funding system.

Perhaps Captain Tom’s successful crowdfunding for the NHS will be a new model of more acceptable taxation for the British public.  It’s not my place to determine how to secure the money needed to have a robust social care system that can withstand the demands of the next COVID-19 peak or the next pandemic.  But in this article, I have tried to highlight some of the systemic issues and leadership shortcomings, from the perspective of a small care home provider.  These need to be addressed in order for the social care system to survive.

Whether politicians continue to give the social care agenda the attention it deserves will, unfortunately, depend on whether the public is prepared to make it a hot topic, as it is focus groups and surveys that tend to drive their attention.  I’m not especially optimistic.  When asked today by the BBC’s Andrew Marr whether he was prepared, like French and Swedish politicians to accept the Government had made mistakes with care homes, cabinet Minister Michael Gove’s muted response was “I accept it has been a particular challenge.”  That’s a “No” then.  But I am determined to do my bit to keep this issue in the public eye, in whatever way I can.  

In the meantime, social care providers have started to warn local authorities that the triple impact of losing residents to COVID-19, struggling to fill vacant rooms during the pandemic, and the extra costs associated with Infection Control including additional staffing, mean they might not survive this crisis, unless the cash being offered by Central Government is released more quickly.  I’m aware, from my connections with other Providers around the UK, that not all Local Councils are acting to support care homes quickly.  David and I are very conscious that our local authority, Devon County Council, has been one of the better ones at delivering the financial aid for care homes.  Without it we would have struggled to make ends meet for the last couple of months.

Continuing on a positive note, there have been some significant highlights during our coronavirus pandemic journey over the last three months.  None the least of which is the response of our team.  We’ve been inspired by the tenacity and bravery of our carers, constantly putting themselves in harm’s way.  Mindful of the 100 plus carers who have now lost their lives to COVID-19, David and I continue to do our part to ensure our team has all the resources they need to stay safe, and we will continue to fight for regular and repeat testing.

We have also been very encouraged by the support we have received from the majority of individuals in various Government agencies, including the NHS and the CQC.  Most have shown as much exasperation, if not more, as we have felt about the systemic shortcomings.  We all realise they are “laying the tracks in front of themselves” as they run to keep-up with the promises being made by the Government, and this has led to much of the inefficiency and disfunction that care Providers and Managers have experienced.  But these people have offered pragmatic and tangible ideas on ways to circumvent the dysfunction in their organisations.  

Our relationship with the Newton Abbot Community Nursing team is worthy of particular note.  Without their focus on doing the right thing, I doubt we would have achieved the testing of residents that we needed in the early stages of our Outbreak.  Especially after the handover request from the SW Public Health Team to our local hospital to issue our first batch of tests for residents got lost in an inbox for three days when the tests should have arrived within 24 hours!

We also feel Central Government has got several things right.  The furlough scheme has helped us support two members of staff who have had to shield for three months, and accessing this funding has been straightforward.  Which has also been the case for accessing the additional funding Central Government is providing through the Local Authorities.  We’re delighted that we’ve been able to start claiming back some of the PPE and additional agency costs we have incurred as a result of implementing higher levels of Infection Control.  

Our main issues with the Government are that they were too slow to act to protect care homes, despite being warned about the need to do so in their own simulation.  And that they too frequently declare victory in delivering PPE and Testing, when the reality for care homes is very different and lives are being lost as a result.  I would like to see a closer link between Government rhetoric and the reality care homes are experiencing.  Stop declaring victory before you’ve actually delivered what you’ve promised.  You might get away with that when introducing a new tax regime to be implemented in the next financial year.  But it doesn’t work when the resources you are saying have been delivered to help survive a crisis are, in fact, weeks away from arriving.

The “protective ring around care homes”, that the Government claims to have put in place, actually feels at this stage more like a partially built dam that is about to burst, with a number of good people trying valiantly to plug the holes with various digits!

I know from other social care Providers around the UK that they have suffered other issues that David and I have avoided.  While we haven’t seen a GP at The Croft since February, we have not had to admit new residents from hospital who may be carrying the virus.  The general infection level in the South West has been the lowest of all Regions, so in this regard we have been lucky.  Care homes in other parts of the UK have not been able to avoid this problem.

Also, uniquely, David and I have had the capacity to wade through and interpret the vast volume of e-mails from various Government agencies, offering help and guidance through the pandemic.  Much of this advice has been overlapping, but occasionally there are nuggets we can’t afford to miss, like sources of additional funding, which is why we give it all attention.  Our other businesses are managed by other people, which has enabled us to focus our attention on just one care home.  I’ve not calculated how much time we’ve spent reading the various e-mails over the last couple of months, but it must be at least 8 hours each a week.  Most Managers and Providers can’t afford this time, especially during a crisis leading to increased risk to life.

Finally, it’s worth noting that earlier this week we were able to declare our home as COVID-FREE, after our two remaining residents who had tested positive passed their 14-day milestone.  We are still lobbying hard to get the tests we need to confirm that all staff and residents are free of the virus.  But, for the time being, we are satisfied to be told by our Community Nursing Team, on behalf of Public Health England, that our Outbreak is over.

Looking forward, we are turning our attention to our own lessons learned, and what we can do now to ensure the virus doesn’t return.  We were never really sure how it entered the home in the first place, and there really could only have been three routes: An asymptomatic staff member or health professional; One of our many deliveries which wasn’t adequately sterilised before being brought into the house; Or an asymptomatic resident returning from hospital in the very early days of the pandemic.  We will never know, but, rest assured, we are very wary of allowing the virus to enter the home through any of these routes again, and we will be a constant voice adding to the chorus of care home Providers asking for regular and frequent testing.

On the issue of whether the current coronavirus crisis will act as a catalyst for a wholesale review of the funding and support for care homes, I am not optimistic, but I am hopeful.  Fundamentally, for good or ill, politicians seem to be led by the nose.  If the UK public continues to define social care as a burning issue that needs to be addressed, the rapidly decreasing resources of the Government might get redirected accordingly.  But, only about 450,000 families have a direct connection to someone living in a care home in the UK.  Will their feelings and passions about the injustices be heard?  It’s certainly my goal to help with that agenda, and it’s been my motivation for writing this article.

Simon Spiller FRSA

17th May, 2020

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 Fellow of the Royal Society of Arts.