Routinely collected care home data
All CHs completed the study proforma (though some CHs did not answer a small number of questions), providing us with their routinely collected data. This included data on the number of beds in the CH and across the organisation; resident occupancy pre- and during the pandemic; CH staffing data including absence, redeployment, employment of agency and bank staff; COVID-19 incidence rates; testing and vaccination rates.
The participating CHs were geographically spread across England, and all had a CQC rating of either ‘good’ or ‘outstanding’. All CHs were part of larger organisations (ranging from 7 to 114 CHs per organisation and between 767 and 5875 beds per organisation). Four of the participating CHs were part of privately run organisations, and two were part of voluntary/not-for-profit organisations. One CH had a ‘Dual’ CQC registration, three had a ‘Nursing’ registration and two were registered as ‘Without Nursing’. All provided services for adults over the age of 65 years, though three also provided a service for adults under the age of 65 years. Most also provided some specialist care, such as care for dementia, learning disabilities, physical health problems and mental health problems. Five CHs had a range of funding sources, including LA, National Health Service (NHS), Clinical Commissioning Group (CCG) and self-funded, while one was self-funded only.
The number of beds offered by the participating CHs ranged between 37 and 73. Some CHs saw no impact of the COVID-19 pandemic on bed occupancy rates. However, some reported a significant reduction in the number of occupied beds, particularly during the first wave of the pandemic, for example a CH closed one floor to be able to isolate floors and staff in the event of an outbreak. Care homes varied greatly on the number of positive COVID-19 cases that had been identified within the home, with one reporting only one case of COVID-19 between March 2020 and February 2021, while another reported 27 cases within November 2020 alone. Most CHs had few or no residents transferred from a hospital or home with COVID-19 throughout the pandemic, though one CH had opened a specially allocated ‘COVID-ward’. They, therefore, received 125 residents with COVID-19 between March 2000 and February 2021. Only two CHs had to transfer any residents from the home to hospital with suspected COVID-19: one had only transferred one patient to hospital between March 2000 and February 2021, but one had transferred nine patients to hospital in March 2020 alone. In one CH, no residents had died within 28 days of a positive COVID-19 test, while 10 residents had died in another home.
A COVID-19 vaccination programme started for residents within participating CHs between December 2020 and March 2021 and all residents had been fully vaccinated in three of the six case study sites. A staff vaccination programme also started in participating CHs between December 2020 and March 2021 and the percentage of vaccinated staff varied between case study sites, from 85% to 100% of staff. All participating CHs said they had taken measures to avoid front-line staff moving between CHs. Half of the homes had employed agency staff during the pandemic, but all those who had said this was within limits (e.g. agency staff could only work at one CH, or only staff from a single agency were used). The number of staff unable to work during the pandemic due to having COVID-19 symptoms varied widely between CHs and from month to month. The maximum number of staff reported being off work with COVID-19 symptoms in any one month was 16. Further information on the routinely collected data for each participating CH is provided in Appendix 4.
Internal layouts of care homes
Care home 1
Care home 1 has 64 en suite bedrooms spread over three floors. Each floor contained resident bedrooms and at least one additional bathroom. The ground and first floors also each had two resident lounges and a treatment room. Other spaces on the ground floor included a kitchen, dining room, nurses’ station and break room, senior nurse manager’s office, administration office and hair salon, while the first floor had an additional activity room.
Care home 2
Care home 2 has 37 beds spread over three floors. The ground floor contained resident en suite bedrooms, bathrooms, three lounges, a kitchen, dining room, office, reception area and staff room. The first floor had resident bedrooms, bathrooms and a nurses’ station, while the second floor contained resident bedrooms, bathrooms, a hair salon and a staff room.
Care home 3
Care home 3 has 45 en suite bedrooms spread over two floors. The ground floor contained resident bedrooms, two lounges, a kitchen, dining room, visitors’ room, hair salon, nurses’ station, break room and manager’s office. The first floor comprised a further three bedrooms, bathroom, kitchen and lounge.
Care home 4
Care home 4 has 72 en suite bedrooms allocated to specific ‘households’ and 18 self-contained apartments. All households and apartments were spread over three floors. The ground floor contained a large bistro and kitchen area, reception desk, administrator office and general manager’s office. It also had two households, each having the same layout with 12 bedrooms, living/dining room, communal bathroom and household kitchen. A further six self-contained apartments were also on the ground floor. The first floor comprised an additional two households and six apartments, a function room, internet café, exercise studio/gym and salon. The second floor contained two more households and six more apartments, alongside other meeting rooms and offices.
Care home 5
Care home 5 has 64 en suite bedrooms spread over four floors. All four floors contained resident bedrooms, a bathroom, at least one kitchen area and two dining rooms. The first three floors also had staff offices and staff rooms.
Care home 6
Care home 6 has 48 en suite bedrooms spread over two floors. The ground floor contained resident bedrooms, three lounges, a kitchen and a dining room, while the first floor comprised of resident bedrooms and a multiroom.
Findings
Social distancing
Social distancing was addressed by all CHs in at least one of their policy documents, although there was considerable variation in the detail of the guidance provided. One CH directed that social distance requirements should be followed but gave no further details. The other five CHs stipulated that 2 m was the required social distance to maintain between residents, staff and visitors at all times, for all activities and in all areas of the home including resident communal areas, dining areas, residents’ rooms, offices and gardens. There were a few exceptions, for example where residents were receiving essential care delivered by staff. For these activities, where maintaining the required social distance was not possible, staff were required to wear PPE including face masks. Policies for two homes discussed the different requirements of PPE depending on the activities being undertaken and whether it was possible to maintain the required social distance of 2 m. Residents were required to socially distance from other residents in all communal areas including the garden and two homes included the need for residents to be advised of this in one of their policy documents. However, one acknowledged that some residents might have difficulty in understanding and following this advice.
There was more guidance in the policy documents about managing social distancing during visits by external visitors, for example residents’ family members, health professionals, maintenance staff, entertainers and senior CH company staff. There was variation in the level of detail of guidance provided and in what aspects of the organisation of visits this guidance covered. For example, one CH gave very detailed guidance about arrangements for visiting entertainers including considering where they would be positioned to ensure at least 2 m social distance from residents, allowing additional space for singers as evidence suggests water droplets from breath carry further during singing. Generally, policies required that visitor access to the CH be carefully managed and supervised to minimise entry to resident communal areas, ensure social distancing and wear a face mask if this was not possible. Most visitors were required to do a lateral flow test (LFT) at the home before entry and policies in some homes stipulated that they must maintain social distancing while waiting for their result.
When family members of residents were allowed to visit, CH policies emphasised the requirement for social distancing. The policy for one home stated that visitors should be asked to verbally consent to abide by the terms and conditions of social distancing while in the home and grounds. The staff were required to set up the home environment to reinforce and maintain social distancing. For example, one home included detailed criteria for the internal visiting room including that it should have an external door, so the visitor did not have to walk through the communal areas of the CH to access it, a separate entrance for the resident, if possible, a substantial floor to ceiling Perspex screen and a hands-free wireless intercom system or mobile phone to facilitate communication during the visit. Other CH policies stated that for internal visits (in the designated visiting room or bedroom visits when allowed) chairs and tables should be positioned to maintain social distance with a screen in place; one home specified that this was also required for exceptional end-of-life (EoL) visits. One CH allowed relatives to remove their masks to aid communication if they remained behind the screen but encouraged them not to raise their voices. There were some differences in the policies about physical contact between resident and their relatives. Most CHs clearly stated that social distance must be always maintained, for example one home specified that relatives must not go behind the screen to touch, hug or kiss the resident. Another CH acknowledged that this would be difficult when visiting policies were revised to allow indoor visiting. Any initial breach of close contact between a resident and their family member should be gently pointed out and advised against. However, one CH guided that close contact should be kept to a minimum with hand-holding being acceptable, but hugging should be avoided and that this must be explained to the visitor. Another CH had a policy that relatives would be supported with physical contact such as hugging with the resident as long as IPC measures were in use.
Some CHs had policies that guided the actions of CH staff when travelling to work. Car sharing among staff was not recommended and alternative arrangements should be made if possible. If there is no alternative, one CH policy stated that 2 m social distance should be adhered to, that staff should car-share with the same colleagues for as short a journey as possible with no physical contact and the windows open for ventilation. They should consider the seating arrangements and try and face away from other passengers. One CH included that CH staff should maintain social distancing as per government guidance when not at work, for example in shops or on public transport.
Isolation
Isolation was addressed in at least one policy document for five of the six CHs. There was more consistency in the requirements for isolation among the CHs, although there was variation in the level of detail provided. Five CHs provided guidance about measures for resident isolation and four provided guidance for staff isolation.
One CH included guidance on how to prepare the CH to implement isolation measures including ensuring each resident bedroom could be used as an isolation room with access to PPE and handwashing facilities. Interestingly, a policy document provided by another home gave details of advising that, at the beginning of the pandemic, all residents needed to stay in their rooms to complete 14 days of isolation keeping away from other residents.
When residents were required to self-isolate all five CHs stipulated that this should be for 14 days (or longer if still symptomatic) and that residents should isolate in single bedrooms with en suite facilities or a designated commode. One home advised that if single room accommodation was not available, then residents should isolate in well-ventilated multioccupancy rooms with designated toilet facilities. The range of reasons stated for the need to self-isolate included the following:
One home provided details of updated guidance of isolation exemptions where many required conditions were met. This included a more detailed risk assessment of newly admitted residents who were transferring from another care facility or planned discharge from hospitals. These new residents who were fully vaccinated and had had no contact with someone COVID-19 positive could take part in an enhanced testing regimen including polymerase chain reaction test (PCR) and LFTs to determine the need to self-isolate. However, following emergency care, residents discharged from hospital were still required to self-isolate for 14 days. A resident who had tested positive for COVID-19 in the last 90 days, had completed their required period of isolation and had no new symptoms was not required to undergo testing. If a resident who was planned to be discharged from the hospital back to the CH or who was a new admission who had tested positive for COVID-19, the CH policy proposed careful consideration of whether there were sufficient staffing levels and availability of a single room before accepting the transfer. Where a resident was identified as a close contact with someone who had tested positive and was fully vaccinated, they did not need to self-isolate.
Where residents were required to self-isolate, one home specified the need to ensure that the resident was kept informed of the rationale for isolation, given the opportunity to ask questions and had an individualised care plan in place. This particular home provided detailed guidance on how to support the resident during isolation including updating the resident’s relatives daily, ensuring that they understand that visits were not recommended and could only happen in exceptional circumstances and authorised by managers, maintaining awareness of the resident’s mental health as they may become anxious and withdrawn and the need to seek further advice from managers and infection control teams if the resident was displaying behaviours that make isolation impossible, for example dementia and non-compliance. Additional support interventions included support from a companionship team (interactions limited to 15 minutes) who would provide an isolation box and support the resident to maintain contact with relatives via video calls. Where a resident refused to comply with isolation and endangered themselves or others, guidance required mental health or safeguarding assessment. If the resident had full capacity and continued to refuse to comply with isolation requirements, the CH manager could discharge the resident from the home. The guidance provided by other CHs was not so detailed but included some important additional activities, for example clearly marking the bedroom doors of residents, updating all heads of department within the home about which residents were isolating so all staff are aware and establishing a safe area for a resident with dementia who walks with purpose when keeping them in their bedrooms would not be possible even if that meant repurposing a communal area.
One CH had sheltered apartments located within the CH and guidance was that tenants must not enter the communal areas of the home site or village and staff were also required to contact them twice a day to check their well-being. Five of the CHs had policies that guided the need for staff to self-isolate. Staff were required to stay off work and self-isolate for 10 days if they had symptoms of COVID-19, a positive test, declined to test, contacted by track and trace, were required to quarantine after returning from a red list country (or amber list country if not vaccinated) or had a breach of PPE when providing personal care for asymptomatic or COVID-19-positive residents.
Restrictions
Restrictions were addressed in at least one policy document for all six homes. There was consistency in the guidance provided by homes although the detail varied considerably. Some of the documents submitted were older documents and the guidance about restrictions had subsequently been updated. Other documents had been updated but still included the older guidance, which reduced the clarity in places.
Resident restrictions
All CHs submitted guidance that restricted residents in some way. As discussed above, residents often had less freedom to move within the home, may have to move rooms if cohorting required this, had fewer visits from family and friends (discussed below), were unable to go to the hospital for routine appointments, their discharge home from the hospital if admitted may be delayed and new residents may experience delays in moving in. Strategies for staff to support residents to maintain regular communication with family and friends via telephone and virtual calls were provided in the policies of some CHs. Restrictions reduced as the pandemic progressed and vaccinations had been given.
Restrictions for families and friends
Most of the guidance in the documents concerned restrictions in visiting for families and friends. EoL visits were restricted in all homes, for example limited to 60 min, one or two immediate family members at a time, no children, wearing PPE and asymptomatic (visit not allowed if the visitor had symptoms). Four CHs included guidance about different types of visits including window, garden and drive-through visits before indoor visits were allowed in government guidelines and visits in designated visiting rooms/suites when indoor visits were allowed followed by visits in resident’s bedrooms when restrictions relaxed further. Two homes provided exceptionally detailed guidance about the different visits including, for example, ensuring residents had sufficient shade in the garden and wore sunscreen on warm days and advising visitors to avoid public transport on their journey. There were consistent requirements for visitors in all CHs even as restrictions began to be relaxed. These included the following:
all visitors were required to be asymptomatic and have a negative
LFT taken at the home before their visit
all visits were time and frequency limited and had to be booked in advance
there were a limited number of nominated visitors (initially one or two, to visit one at a time)
no or little physical contact with their family member was allowed
gifts had to be given to a member of staff to be wiped down
visitors were not offered refreshments or able to use toilet facilities.
Although visitor restrictions relaxed in line with government guidelines, some CH policies continued to emphasise the need to risk-assess visits and rules varied according to this assessment. For example, although from July 2019 there were no national limits on the number of nominated visitors or how many can visit each day, the number of visits available in some of the CHs was dependent on how many could be accommodated each day with the time needed to support visitor testing and in some cases supervising the visit, the layout of the CH, length of visit and the need to ensure equity in visiting for all residents.
One CH provided guidance about residents leaving the home. Where these visits were considered high risk, for example emergency admissions to hospital, the resident should self-isolate on their return to the CH. However, other low-risk visits were supported without the need to isolate on return, for example spending time with family and friends, overnight stays in the family home, participating in community groups and volunteering and routine hospital appointments. During these visits, COVID-19 precautions, that is social distancing, handwashing and face masks, should be followed. All CHs had a policy that emphasised that in the event of an outbreak of COVID-19, that is two or more residents or staff testing positive then restrictions would increase.
Restrictions for care home staff
Restrictions for CH staff were addressed by at least one policy document for most CHs. Although the guidance was not comprehensive, it was clear that CH staff had considerably adapted the way they worked to provide care for residents and to implement and support the restrictions (and the effect of the restrictions) for residents and all visitors. For example, guidelines of several homes described the role of staff to reassure visitors, provide advice about communicating with masks on and, where assessed necessary, to supervise the visit. One home suggested that staff should advise visitors to dress and style their hair to help the resident recognise them and prepare the resident for a visit by showing them photographs of the person who is due to visit and talking to them about their relationship. The role of housekeepers had also altered because of changes to cleaning and hygiene protocols and the increased frequency of cleaning required including between visits. One home suggested the nomination of a COVID-19 co-ordinator for each shift to ensure adherence to infection control and COVID-19 policies, which should be discussed in staff supervision.
One home required that vulnerable staff should not provide care for symptomatic residents and should discuss redeployment or furlough with their line manager. Furthermore, this home required that staff adhere to PPE protocols and national lockdown guidance outside work. Failure to do so may result in disciplinary action or referral to safeguarding. Staff were required to participate in routine COVID-19 testing at the home, and the guidance in one home stipulated that the CH manager should ask to see the result for verification. All staff with a positive test or who were symptomatic were immediately sent home and required to do a PCR test. The use of agency staff was not recommended unless necessary and approved by the regional manager in one home.
Restrictions for healthcare professionals and other visitors
Restrictions for healthcare professionals and other visitors were addressed in at least one policy document in each CH, although with varying degrees of detail. All visits to each home were required to be booked in advance and approved by the home manager and visitors were required to complete a visitor questionnaire. In one home, the only unannounced visitors who would be allowed to enter were CQC inspectors and the police. All visitors were required to be asymptomatic and have evidence of a negative COVID-19 test when these were available. Multi-site CH staff, NHS and CQC staff take part in routine testing but are still required to show evidence of a negative test to be allowed to enter the home. Homes gave guidance for essential and non-essential visitors. Essential visitors included healthcare professionals providing urgent or emergency assessment and treatment, for example general practitioners (GPs), allied health professionals (AHPs), district nurses and property maintenance staff for emergency repairs. These occur as required even during an outbreak. Non-urgent GP and AHP consultations were required to be agreed at the local level by some homes, although they could be undertaken by audio or video-link if preferred. Two homes had a policy where a member of CH staff substituted for a visiting professional to perform an activity in situations where it was considered safer for the professional not to visit or when the professional was unable to visit. For example, a RN member of CH staff could provide care as part of the district nurse’s ongoing treatment plan when they had the required skill and when this was agreed with the district nurse and the CH manager. Similarly, another home had a policy where non-medical care staff could verify the expected death of a resident where the GP and home manager agreed on an approach of how to manage this.
Some routine visits by multisite centre home employees, and operational and support staff were supported to continue in some policy documents on the instruction from heads of department, although they could only visit one home in a day. One home specified the use of Microsoft Teams to support oversight of governance and management with some additional in-person visits at least every 3 months or more frequently if needed. Where onsite visits were undertaken, staff were required to change into uniform/alternative clothing on arrival and leave these clothes at the CH to be laundered (or, if necessary, taken home in an alginate bag and put in a washing machine immediately without removing them from the bag). However, if there was an outbreak during that time, one home had a policy that required these staff members to work exclusively at that home for 14 days until the outbreak was fully resolved. Property maintenance staff who work across several homes were required to wear full PPE and disposable overalls and have no contact with residents unless emergency work was required, and risk assessed by the home manager and facilities manager.
Non-essential visitors included hairdressers, entertainers and prospective customers/family show-rounds. These visits did not occur early on during the pandemic, although as restrictions relaxed, they were allowed to start with strict policies of COVID-19 testing, PPE and social distancing measures. In some CH policies, some visitors still have no access, for example community groups such as rotary clubs, schools and nurseries and other social groups.
Zoning and cohorting
In at least one of their policy documents, zoning was addressed by three and cohorting by five of the six CHs. There was significantly less guidance about these measures, particularly zoning, which was rarely mentioned. Isolation in a single room, where required, was seen as the best approach where practicable. However, in two CHs, guidance was given to cohort residents when there was an increase in the number of residents who needed to be isolated, single rooms were not available and when there was a reduction in the number of staff available to provide care. Cohorting residents, including newly admitted residents, where isolating in single rooms may impact their emotional well-being, was also considered by one home. Generally, cohorting or grouping residents in the same area of the home and ensuring that they have separate dining and activity facilities and, where possible, separate entry/exit doors were presented as a measure to minimise the risk of the spread of infection by limiting the movement of residents and staff between the different areas of the home. However, one home did caution that a group approach to infection control increased the risk of spread to residents with no symptoms.
Furthermore, the guidance stated that residents with suspected COVID-19 should not be cohorted with those with confirmed COVID-19 and neither should suspected or confirmed residents be cohorted next to those who are immunocompromised. When working with a cohort of residents, staff were expected to use PPE differently. The single-use policy no longer applied. It was acceptable to wear the same PPE for a session of care, which refers to a period of time when a care worker was undertaking duties in a specific care setting that ends when the healthcare worker leaves the care setting/exposure environment.
Guidance about cohorting also referred to grouping staff in the same location/area within the home, which should be planned as part of the scheduling. Staff were guided to form part of the cohort and, as far as possible, avoid movement between cohorts, including interacting with colleagues outside their cohort on breaks and other activities. In situations where this was not possible, guidance stipulated that staff should undertake good infection control and prevention measures by changing PPE and thoroughly washing hands.
There was some overlap or lack of clarity about how the terms zoning and cohorting were used in the documents. In some policies, residents who were isolating as a cohort were placed in a designated unit, floor or wing. One home acknowledged that residents and staff might find it challenging to understand cohorts. If so, it was suggested that forming safe zones, for example, the green zone or blue zone may indicate safe areas. Anything outside their own-coloured zone becomes higher risk so should be avoided or further IPC precautions should be undertaken. Similarly, high-risk infection hot spots, that is areas where staff and/or residents’ access from different cohorts (or zones) such as the reception area, main lounge and medication room (for staff), were called red zones. Everyone in the home was expected to be made fully aware of the red zones and the need to take extra precautions and reduce movement within these areas.
