It has recently been reported that care home workers are able to opt-out of the mandatory COVID-19 vaccination requirement by self-certifying that they are medically exempt.
Thursday 16 September 2021 was meant to be the deadline for all carers to have received their first COVID-19 vaccination. This mandatory vaccine requirement for all care home staff has been a source of constant debate since it was announced, with growing concerns that a significant number of care homes may be forced to close and thousands of staff from an already depleted workforce risked losing their jobs if they declined to have the vaccine. The government has been lobbied by both providers and unions that care home workers had been “singled out” and the very real possibility of the doomsday scenario of a mass exodus of care home staff in England, so it perhaps does not come as a great surprise that Whitehall has taken some evasive action (perhaps with an indication as to how many staff had refused the vaccine). However, how effective will this self-certification opt out process be and is it only a temporary fix to what has become a polarising political issue.
The guidance for friends and family visiting loved ones in care homes was updated on 4 March 2021 to reflect the announcements in the new lockdown roadmap published on the 22 February 2021. The full guidance can be found here.
Each care home will allow its residents to name one person who can make a regular indoor visit, which as far as possible should remain the same person. The single named visitor will need to take a rapid (lateral flow) test and wear PPE every time they visit. This affords the individual a regular indoor visit, sitting in the same room as their loved one, with no screen between them. The government still strongly advises against physical contact and that close contact like hugging should be avoided.
As was highlighted in this blog, the Vaccines Minister Nadhim Zahawi has announced a ‘targeted and time limited state backed indemnity’ for care homes which are registered as Designated Settings or intending to register as a Designated Setting, and which are unable to obtain commercial insurance. The question is, will this relatively short-term move have the impact that is needed right now to protect the NHS and care sector?
So what is a Designated Setting? It is essentially a care home which has applied and been assessed by the Care Quality Commission (CQC) as an appropriate setting to care for COVID-19 positive patients who are discharged from the NHS and who no longer require an acute hospital bed. The objective is of course to relieve pressure on the NHS as it copes with the winter crisis.
The aim is that there is at least one Designated Setting in each local authority ‘as soon as possible’.
How are the care homes assessed? The care homes are assessed by the CQC using its Infection Prevention and Control framework (IPC). Assessments are made to ensure patients are being physically separated, that there is a dedicated workforce and appropriate emphasis on ventilation.
The CQC is using an ‘eight ticks‘ approach in order to give the public an overview as to factors such as the availability of adequate PPE, that staff are properly trained to deal with outbreaks and the appropriate processes needed, that shielding is being complied with and hygiene practice is promoted.
How many Designated Settings are there currently? As at 12 January there were 135 approved Designated Settings providing a total of 1,624 approved beds. The coverage across the country is however currently variable – there are only 87 approved beds for instance in London, but 381 in Yorkshire and the Humber.
Testing of CQC inspectors Up until now CQC inspectors were not tested for COVID which was a source of concern for many. It is now proposed that inspectors will be tested weekly with the testing being rolled out in the coming weeks. It is not clear however why there is to be a delay since care home staff are already being regularly tested.
What is the state indemnity scheme going to cover? The indemnity will cover claims for clinical negligence and employers’ and public liability where the care home provider operating a Designated Setting has been unable to secure such cover in the commercial insurance market..
The clinical negligence aspect will be covered by the Clinical Negligence Scheme for Trusts (CNST) supervised by the DHSC and NHS Resolution.
However, as things stand this indemnity will be in place only until March 2021 and is to be reviewed in mid-February.
How helpful is this scheme going to be for the care home sector? One of the concerns for care home managers seeking to participate will no doubt be the ability to provide a dedicated COVID- 19 workforce, particularly given the pressures on staffing already apparent.
If Designated Settings are to be contained within care homes also containing those who have not been exposed to COVID-19, reassurance around dedicated staff, PPE provision, social distancing and adequate ventilation may not be enough to convince service users that they are in fact completely safe.
It remains to be seen how successful the scheme will be for care home operators who have difficulty in obtaining commercial insurance cover for COVID related claims. The impact on the NHS of course will depend on just how successful this scheme actually is in freeing up acute beds.
Given however that the indemnity scheme is limited in its time frame and scope the concern must be that it will simply be insufficient to make any real impact on the problem.
The topic of visiting care home residents continues to hit the headlines this week.
The government published guidance for visiting care home residents this week. Previously care home visits had been banned in Tier 2 and 3 areas. The new guidance confirms that visits may continue during the lockdown period for England, so long as this is done in a COVID secure manner, using for example PPE and social distancing, and recording visits for Test & Trace. The new guidance comes following widespread pressure from charities and industry bodies to allow visits.
The Department of Health and Social Care contacted English care home providers via a letter last Friday to warn of the rise of COVID-19 cases in care homes. This message was as a result of new data based upon regular testing of staff and residents now undertaken in the majority of care homes in England. Testing data shows new infections have quadrupled in recent weeks, in particular amongst staff. The concern is that the infections will spread to vulnerable residents.
Care homes have undoubtedly been significantly affected by Covid-19 and the manner in which cases have both spread and been controlled has been criticised across national media outlets. The Office for National Statistics, reported on 3 July that for deaths registered up to 9 May 2020, 12,536 involved Covid-19. The number may of course be significantly higher as testing has not been undertaken in every death.
A recent study by NHS Lothian and Edinburgh University , looking at care-home outbreaks in a large Scottish health board has been undertaken. The study considered 189 care homes in the Lothian area where more than 400 people died from Corona.
The study identified that 37% of care homes considered within the sample group had experienced an outbreak of Covid-19 and significantly the larger the care home, the larger the associated outbreaks. NHS Lothian and Edinburgh University found the likelihood of the infection spreading increased three fold with every increase of around 20 beds. Homes with less than 20 residents had a 5% chance of outbreak, compared with a figure between 83% and 100% for homes with 60 to 80 residents.
The concerns with how the virus was controlled in care homes is still relevant considering the potential for a second wave. Lessons can and should be learned to prevent such significant numbers of deaths occurring again and actions taken to lessen the impact of a second wave. The study found that many of the deaths were due to outbreaks in only a few locations. This essentially means there is a wide pool of care homes that Covid-19 has not broken into, and thus a wide pool of potentially vulnerable residents that will need further protection ahead of any second wave.
The possibility of creating ‘bubbles’ within care homes has been suggested. These ‘bubbles’ in a care home setting could be created from sectioning larger Homes into smaller units. Residents would be assigned to a small sub-unit and particular staff would also be assigned to those units. This way interactions between residents, staff, and the general footfall through the home could be limited, reducing the potential spread. Staff could be assigned to certain areas, and more scheduling of bubbled staff could be introduced for the running of the care home, such as cooking, cleaning and maintenance.
This in theory sounds like a possible way to reduce the outbreaks within care homes, however this will of course take considerable planning, resources, and staffing which will in turn increase the funding required to support the care homes. Consideration will need to be given to individual set ups of care homes, and the possibility to create small units within them, especially for homes with residents who may be prone to wandering, such as those suffering with dementia.
Pressure will likely continue to mount on the government, requiring clearer advice, and forward planning for a potential second wave and to ensure steps are in place to prevent the impact of any second wave.
On 6 May it was announced that five residents had died at a care home on the Scottish island of Skye at the centre of a COVID-19 (C-19) outbreak on the island. 57 residents and staff at this care home have tested positive for C-19. Ten deaths have also recently been reported at a care home in East Dunbartonshire.
Statistics from the National Records of Scotland show that by Sunday 3 May there had been 2,795 deaths in Scotland where C-19 is mentioned on a death certificate. More than four in ten of those deaths (42.8%) have been in care homes. The proportion of deaths in care homes has also been growing, accounting for almost 60% of C-19 deaths between 27 April and 3 May.
We have recently written several blogs regarding various COVID-19 related problems the care sector is facing. In particular the supply of PPE and the effect of COVID-19 generally on staffing levels and management of service users are critical issues.
The Government and other bodies such as the Care Providers Alliance are urging health and social care providers to ensure they have done everything they can to prepare for a potential No Deal Brexit on 31 October.
The National Audit Office published a report at the end of September noting that whilst the Department of Health and Social Care had undertaken a lot of work since June 2016 to prepare the sector for leaving the EU, there was still a lot of work to be done before 31 October in respect of the social care sector. For example the report notes that whilst the NHS has taken steps to stockpile medication for immediate use across the healthcare sector, care homes often rely upon non NHS suppliers for supplies of items such as rubber gloves. The Department did not originally advise the social care sector to stockpile such items, but rather advised that care providers should be simply “ready to deal with any disruption”.
The CQC has today released a review of oral health and dental care provided to those in care homes. The report concludes that this is poorly implemented in care homes. The review is based on 100 visits to different care homes by dental inspectors and oral health specialists.
There are specific NICE (National Institute for Health and Care Excellence) guidelines to cover dental care for persons living in residential care but in the majority of cases these were not being followed. Residents generally had their oral health assessed upon admission, but often care home staff were not aware of the NICE guidelines and had not had specific training on oral health. More worryingly, over half of the care homes surveyed had no policy to promote oral health, and nearly three quarters of the care plans reviews did not cover oral health or only partly covered it.
The CQC comment in the foreword to the report highlights the fact that the elderly of today generally are more likely to retain their teeth than earlier generations. Good oral care is essential for those in care homes to reduce pain and reduce the risk of malnutrition. Oral care was also often not joined up meaning that when emergency dental treatment was required, the homes would call a GP, or 111, or send the person to A&E – thereby placing a strain on already overworked services.
The care sector should carefully consider this report with a view to future policies and management of residents’ oral health otherwise this may be an area that residents and families focus upon in terms of claiming for damages.