Overall impact on staff

Care home staff recounted the toll taken on their emotional and physical lives by working in CHs during the pandemic. This ranged from dealing with changed working routines and the burden of wearing PPE to feelings of fear for themselves, their families and those they cared for. Staff also talked to us of their discontent with how the UK government had handled the pandemic, especially regarding CHs.

Care home staff talked of the many ways that their day-to-day working lives had changed because of the COVID-19 pandemic: the most notable of which was having a far busier workload. Some staff felt their roles had become more ‘task-focused’, emphasising sanitising the CH, organising visitor appointments, taking temperatures and testing residents and visitors for COVID-19. They also talked frequently of the changes they had experienced around wearing additional PPE. Access to adequate PPE became a significant issue in the early stages of the pandemic. Staff did understand and appreciate the value of PPE during the pandemic; they trusted it and were grateful that it had allowed them to continue working safely. However, almost all staff talked of the great impact PPE requirements had upon them and their residents. For staff, these regulations involved the additional burden of changing their clothes and PPE regularly and wearing a mask and/or visor all day. Some staff felt they could not breathe properly when wearing a mask, while others talked about masks making them feel hot or developing spots on their face and sores around their ears. Staff also felt PPE made it more difficult for residents to recognise and communicate with staff, particularly those residents who were hard of hearing and relied upon lip-reading or those who had vision problems. Sometimes staff had to lift their mask briefly so that residents could understand what they were saying, while other times staff would stand across the room and talk ‘really loudly’ to residents or write down what they wanted to say on paper. It was felt that seeing staff in full PPE could be ‘scary’ for some residents, especially those with cognitive problems. It could also negatively impact the ability of residents to connect with staff and for the CH setting to feel like ‘home’:

‘The thing is of our profession we’re used to being quite emotive and, you know, speaking with our face and a large proportion of your face is blocked … I think also wearing the aprons and the gloves it’s like a clinical environment, so again, people living in the private sector, they’re not used to clinical environments. This is home’.

(Lead Nurse)

However, while problems with PPE were more prevalent at the start of the pandemic, many staff said that PPE had become ‘just a way of life now’ and that staff and residents were becoming more accustomed to masks. Thus, the extra work involved in communicating and working while wearing masks had become ‘baked in’ to the job’s demands. However, there was also some suggestion that staff roles had begun to become less task-focused as the pandemic progressed and that some rules and regulations had been relaxed over time. Staff expressed the hope that the country was ‘over the worst’ of the pandemic and that life in CHs could soon return to normal, though there was also an acceptance that COVID-19 restrictions may have to continue for some time.

The impact that the COVID-19 pandemic had upon CH staff must not be underestimated. One HCA described their experience as being an ‘emotional rollercoaster’, and several examples were highlighted of the sacrifices that staff had made and the traumas they had experienced. When information was limited at the start of the pandemic, the staff talked of how ‘frightening’ they found working with residents who were very poorly with this new, unknown virus. Many had also feared for their own safety at times, with concerns around catching the virus from residents and what would happen to them if they did:

‘… I tested positive at the beginning when it had first kind of come out … I was hysterical because I thought I’m going to die’.

(Lead Nurse)

Many staff also had fears for the safety of their families and some had chosen to separate themselves from their children and vulnerable relatives, which came at a high personal cost:

‘… I gave my daughter up for 7 weeks at the beginning of the pandemic, purely because I didn’t … want her to be in danger, I didn’t want my mum and dad to be in danger … I didn’t see her and I’ll always remember that day when she came to back to me and I think it’s just insight into what people have given up during this horrific time’.

(Deputy Manager)

‘For months and months and months, just on a personal level, me and my husband didn’t even give each other a hug and a kiss because … the environment I work in, I wanted to protect him, he wanted to protect me, you know, and that was like, “Oh my goodness, I can’t even give me husband a kiss’, you know”’.

(Lead Nurse)

In addition to their stresses at work, some CH staff were experiencing family illness and bereavements, partners’ job losses, broken marriages, cancelled healthcare treatment and financial worries as a direct consequence of the pandemic. There were reports of some staff expressing suicidal thoughts or self-harming, and one manager undertook a mental health first aid training course specifically to help their staff with their mental health. Other staff had been referred for professional psychological and physical health review:

‘… slowly, slowly that energy, I could feel it was fading away, and yeah, I ended up having a psychiatrist on Skype, and medication for depression and … a machine to monitor my heart, because of the stress’.

(Senior Nurse)

Many staff said they were mentally and physically tired and looked forward to a holiday or a break from work. Some CH staff had left employment due to their fears of working in CHs during the pandemic, and this was difficult for those who remained and perceived to be a significant loss to social care. Those who remained working throughout the pandemic were described as ‘brave’, with one manager stating they had ‘real admiration for them, because we did battle’. Some staff said they had struggled and admitted that they had considered leaving their role but continued to return to work each day to support their colleagues and residents:

‘… I used to go home some nights and I didn’t even talk. I used to go home, have a shower and go straight to bed because I was that tired and upset and it did make me … it made me feel quite sad and withdrawn. Then next day you just have to boost yourself back up again because you couldn’t let residents see you being like that’.

(HCA)

Many staff compared their own CHs to those that had been more badly impacted with infections and deaths from COVID-19 and felt relieved that their experiences were not as bad as they could have been. This was generally attributed to the interventions put in place in their CH and the hard work and dedication of their colleagues, and a sense that their CH had simply been ‘lucky’. There was an acknowledgement that even when staff had questioned the interventions and the sacrifices that residents, their families and staff had made, the ultimate reward was that their CH had remained safe:

‘… even in those difficult moments where you may question what you know, when you’re talking about what’s morally right and what’s, you know, safest and things like that, what we come back to is, well, it’s worked for us in the sense that from a COVID point of view we’ve managed to keep the residents, you know, relatively healthy … the processes that we put in place have obviously made a massive difference and it could have been very different if we hadn’t been doing it’.

(Nurse)

For many staff, the difficulties experienced during the COVID-19 pandemic were compounded by the government’s response to CHs. Some staff felt the government had abandoned them in the early phase of the pandemic and that CHs had not been considered or given appropriate guidance early enough in the process. One care assistant stated, ‘… the Government didn’t do nothing until people were dying’. Some staff criticised the ‘blanket approach’ to government guidance, which did not consider the many individual differences between CHs and CH residents. The guidance was often too long and complicated, with many different policies to consider. Others were confused by the rapidly changing rules for CHs set by the government and the fact that they found out about these rule changes at the same time as the rest of the population, which meant that homes did not have enough time to implement them appropriately:

‘… it seemed like every day there were different rules, government guidelines were changing, chopping and changing, we were expected to chop and change just the same’.

(Lead Nurse)

‘… the guidance will be published at 5 o’ clock on a Friday afternoon, and we’ve got, we’re sort of dealing with phone calls and hassles all over the weekend and we’re going, “I don’t know anything about this, what do you expect me to say?”’

(Deputy Manager)

One manager acknowledged that managers had to use their ‘own common sense and … knowledge’ when interpreting the government guidance, rather than simply follow it directly, while a Unit Lead talked of needing to select the parts of the guidance that were relevant to their individual setting:

‘… a lot of it was delving into the guidelines and actually working out, “Okay, what needs to be brought in?” Particularly with the early guidelines because it was all so over the top and a lot of it was written for acute places or places with live infections and it was sort of going, “Whoa, hang on a minute, we haven’t got anything here so at the moment we don’t need to change anything”’.

(Unit Lead)

Where applicable, managers also appreciated having the support of the senior management team in their larger CH organisation to help them interpret and implement government guidance. Several staff also talked of their passion and dedication for their role and how this had helped them get through the difficult times during the pandemic. Staff expressed great fondness and care for their residents and colleagues, often referring to those within the CH setting as a ‘family’. They were driven to provide their residents with the best possible experience during a challenging time. However, many also felt that CH staff had not been ‘recognised’ by the government (or by the population as a whole) in the same way as their NHS colleagues, which made them feel undervalued. One deputy manager said that working in a CH could sometimes be a ‘thankless job’, while others thought that the government could show they valued care workers by increasing their salaries:

‘… since we’ve been working in this pandemic they’ve been singing about the NHS, the NHS, the NHS. Us in the care home, we didn’t get nothing, nothing, and we worked so hard during this period. […] It’s only the NHS that was getting all the praises, they had the money, the increment, everything, we didn’t get nothing’.

(Care Assistant)

The following section highlights CH staff’s thoughts and experiences of the specific social distancing and isolation interventions put in place in their CHs during the COVID-19 pandemic.

Social distancing

Social distancing measures affected how staff could care for residents. They also changed how staff related to one another. This section discusses how staff experienced social distancing and the workload and logistical challenges they faced in maintaining it. As we demonstrate, staff were sceptical of the benefits or practicality of social distancing in CHs.

Social distancing measures involved residents being required to maintain a 2 m distance from each other. At first, some CHs tried to maintain social distancing by placing ‘Do not use’ signs on a proportion of their communal chairs, but this confused residents. Instead, staff felt it more appropriate to remove some chairs from communal areas to limit the number of people who could congregate together, or place coffee tables between chairs to ensure adequate spacing. However, limiting capacity in communal areas made it harder to organise usual events and activities and meant that fewer residents were able to participate, which staff found disheartening. Homes also limited the number of residents who could eat in the dining room together and ensured that dining room tables and chairs were appropriately spaced. This occasionally required CHs to turn communal lounges into extra dining spaces.

Care home staff were equally required to distance themselves from their colleagues socially, which led to staggered break times and limits on the number of staff allowed in break rooms. This involved reorganising rooms to create additional staff break spaces in some homes. Although staff and residents were also supposed to maintain a social distance from each other, many staff reported this was impossible to fulfil when providing personal care and that exceptions needed to be made at times:

‘… there’s no way on earth that I’m going to stay … 6 foot away from a resident at any given time, you know, it’s just impossible. We’ve got people who may need assistance when they need to eat or when they need a drink, or people who might need personal care. You can’t keep away from people’.

(Senior Support Worker)

A key implication of social distancing was its impact upon residents and the confusion these rules caused some of them. Several staff stated that residents found it hard to be distanced from their friends and could not understand why they could not sit closer to each other. This confusion was particularly notable for residents with dementia, who struggled to comprehend or remember social distancing rules, and some staff talked of the difficulties of ‘policing’ these restrictions while simultaneously trying to maintain a sense of ‘normality’ for their residents:

‘We try to move the chairs or the seatings where they are. They still come, they still push them back together, they want to be together. It’s really hard with them because, due to their dementia, they don’t understand what we’re trying to do. We try to explain, they say “Oh, yeah yeah”, but after 5 minutes you come back, they’ve done the same thing again’.

(Team Leader)

Social distancing measures also resulted in greater workload for staff, who were tasked with staying ‘vigilant’ around residents’ distances from each other and maintaining appropriate cleaning regimes when residents moved around the home. The importance of touch, for both residents and staff, was also regularly highlighted, with staff feeling that social distancing measures had denied many residents of this vital need. Many staff spoke of the critical role that hugs play in CHs. Residents wanted hugs from each other and from staff members, particularly if they were feeling low in mood or missing their families, and they could not understand why staff members would not hug them anymore. The fact that staff were able to have physical contact with residents while delivering personal care but could not hug them was also confusing:

‘… the residents found that hard. They’d say, “Well you’re washing and dressing me! You’re washing me, why can’t you just give me a hug?”’

(Manager)

Several staff described themselves as ‘tactile’ or ‘huggy’ people, who enjoyed hugging their residents and felt desperately sad at not being able to comfort them in their usual way. For staff who lived alone, receiving a hug could be of crucial importance to their own well-being and to have this opportunity for physical contact be denied had been particularly upsetting:

‘… sometimes that’s all you need, is a hug from somebody you work with. I mean, I go home to nobody, I live by myself, so sometimes a hug at work is probably all I need’.

(Senior HCA)

Many staff used the word ‘family’ to describe the relationships between staff and residents in CHs and talked of the loss of social interaction caused by social distancing measures. Care homes were perceived as a resident’s home rather than an institution, which made some staff question whether social distancing was appropriate, both practically and conceptually. For example, one CH was previously a residential property and was not purpose-built. As such, staff felt there was not the physical space for social distancing to be implemented successfully. Other homes were described as ‘lucky’ because they had several, large communal areas or wide corridors, making social distancing more achievable. One CH operated under a village model described as ‘designed for people to mix’. This involved staff and residents cooking and eating their meals together and residents from different households and apartments mixing freely. Such opportunities to socialise had been limited due to social distancing measures, leading to concerns about ‘institutionalising’ the village and causing it to lose its natural environment and family feel. This brought into question whether abiding by social distancing measures was always in the best interests of the residents. For instance, one staff participant told us of a woman with dementia who believed he was her husband and enjoyed holding hands with him while listening to music. This care worker faced the dilemma of whether to maintain social distancing rules with the resident or continue offering her the physical closeness that she needed. He concluded

‘I couldn’t turn round to that particular lady and say, “No, I can’t do that” … It’s not in her best interests for me to do that. So, again, swings and roundabouts, you’ve got to take into account the guidelines, but you’ve got to take into account people’s best interests as well’.

(Senior Support Worker)

In this scenario, the care worker felt that by being fastidious with changing his clothes and PPE and washing his hands regularly, he could safely provide the resident with the contact she needed and overlook the social distancing guidance. Indeed, other examples were provided of CHs either trying and failing to implement social distancing measures or choosing not to implement them entirely, due to the belief that they were impractical or unsuitable for CH environments. While most of the staff interviewed found social distancing measures challenging to implement, several felt that good support from management made the process easier. There were few positive outcomes associated with implementing social distancing in CHs, although one member of staff believed it had resulted in fewer normal winter bugs and the associated deaths:

‘… I would actually say we had a very, very easy winter because of social distancing because we didn’t get all the coughs and the colds come in and we didn’t have a lot of end of life because of that’.

(Deputy Manager)

Isolation

All staff talked about the isolation regulations that were put in place for CH residents. Initially, isolating residents were asked to stay in their rooms for 14 days, but government guidelines later changed to 10 days. All meals and care were delivered within the isolating resident’s private room. Staff entering the room had to maintain a social distance from residents and ensure their PPE was changed upon entering and leaving the room and disposed of appropriately. Some CHs used disposable plates, and cutlery for isolating residents, while others ensured that any crockery used in isolation was washed separately. There were many reasons why CH residents might be asked to isolate in their private bedroom. Still, across all CHs, residents were isolated if they displayed COVID-19 symptoms and were waiting for a test or had received a positive COVID-19 test result. Residents were also required to isolate when returning from hospitals or entering the CH as a new admission. This was to limit the likelihood of residents bringing COVID-19 into the CH, but both scenarios presented unexpected issues. For example, some staff felt that the requirement to isolate after attending hospital led to a reluctance in residents to attend hospital appointments and a disinclination from staff to refer residents for hospital care:

‘… some have chosen not to go to hospital appointments if they don’t feel it’s necessary … so they won’t get isolated … they like to be downstairs in activities, so they’ve chosen not to go to hospital because of the risk of being isolated’.

(Manager)

Many staff felt that new admissions to CHs had the most challenging experience with isolation regulations. This was because (1) the transition from home to CH was already difficult enough for people without the need to also isolate alone and (2) new residents had been unable to see the home as it usually operated, to participate in any of the activities, or to socialise with the other residents and staff. For these reasons, it was felt that new residents were often unhappier with their experience of moving to the CH, with some describing them as feeling ‘alienated’ from the others:

‘We had a couple in recently and he just said to me, he said, “My family have put me on this cruise, they told me that there was bingo and everything and I haven’t seen any of it. I don’t reckon much to this cruise”. So, it is difficult’.

(Senior HCA)

Some CHs also operated additional isolation procedures from those previously mentioned and staff talked of the specific challenges. For example, in the first national lockdown (Spring 2020), one CH isolated all residents in their private bedrooms as a precautionary measure, due to the lack of information available at this time. In a different home, operating under a village model, residents lived in a series of smaller households of 12 people and these households were treated as separate subgroups. When there was a confirmed case of COVID-19, the whole household was required to isolate but the rest of the village was not (for more information about isolating residents in subgroups, see the ‘Zoning and cohorting’ section). These isolation procedures had both positive and negative implications. The benefit was that fewer staff and residents were required to isolate during COVID-19 outbreaks and the negative being that this could result in a disparity between households. Another difficulty with this approach was that if several residents in a household caught COVID-19, then everyone within that household could remain in isolation for a long time:

‘… if you had one resident that had it and then we had another resident a few days later, the isolation period could go on and on and on. […]. So I know at one point we had a household, it could have been like 28 days or more that they were in isolation for, which is a long time’.

(Manager)

In a further CH, a senior management decision was made to open a ‘COVID ward’, where people hospitalised with COVID-19 could be discharged to recover. Everyone on this ward was required to isolate within their own rooms (locks were placed on bedroom doors) and rigorous infection control procedures and minimum staff contact rules were put in place. However, the decision to open this ward caused serious concern among many of the CH staff, including the CH manager, and some staff refused to work on this ward:

‘… the fear was spreading through the home … the first staff meeting we had I told the staff about COVID and the ward coming in, one of the staff stood up to me and said, “You’re going to kill all our residents.” That’s massive and she left. Because I would never kill anyone [Pause] That was a real … powerful statement to say in front of a whole staff team who are about to take on COVID’.

(Manager)

Yet despite these fears, the CH staff continued to work together and support each other, with many volunteering to work on the COVID ward and staff members drawing upon their previous experience of working with patients with MRSA or AIDS (acquired immunodeficiency syndrome) to help ensure that strict infection control measures were followed. Staff spoke of the pride they felt at continuing to care for residents on this ward, despite their fears, and hoped that they would be recognised for the bravery this required. Finally, some residents chose to stay within their own room even where there was no requirement for them to isolate. This was due to fears that they might contract COVID-19 if they left their room and felt safer self-isolating. Although staff tried to encourage these residents to leave their rooms, they acknowledged that this was the residents’ decision to make.

There were several negative repercussions of isolation requirements in CHs. Some staff felt that potential new residents had been deterred from moving into CHs because of the isolation requirements and one home was required to shut down a whole floor due to the lack of new admissions. Some CHs also felt restricted around whom they could accept as a new admission during the pandemic. Staff acknowledged that they only felt able to admit residents who were physically and mentally capable of isolating themselves and not those who were likely to ‘walk with purpose’. In addition to having financial implications for the CH, some staff also said they felt uncomfortable about making decisions on admission based upon residents’ ability to remain in isolation. The notion that isolation requirements went against the ethos of the CH environment was raised by a couple of CH managers, who worried that these interventions violated their caring instincts and ruined the ‘family’ feel of their homes. One deputy manager even expressed concerns that isolating residents felt like ‘institutional abuse’ or a violation of their human rights, but worried that there was no other safe alternative:

‘… we were having to say to these residents who like to come out of their room, “No, you’ve got to stay in your room”. To me, that was almost like institutional abuse, and I was like, “I need to safeguard the home” … so there was such a conflict of interest in terms of we’re doing this God awful thing but for their best, to keep them safe and it just didn’t … sit right with me because it was against every kind of nursing instinct and caring instinct that I’ve got in my body. But again, as all things, upon reflection, I dread to think what would have happened if we hadn’t have done that and if we don’t still do that for new people that are coming in’.

(Deputy Manager)

Some staff also stated that they could not force residents to stay in their rooms; therefore ‘adjustments’ sometimes had to be made, where this could be done safely:

‘… if the balcony was free, perhaps they could come out if there was nobody else about and sit on the balcony still isolating sort of thing. So, it was trying to look at different ways where we would isolate that person, but not close them off completely from everybody else’.

(Manager)

When residents were asked to isolate within their rooms, it was acknowledged that this was a difficult task for them, particularly when they had cognitive impairment or did not understand what was required of them. Staff had to repeatedly remind and explain to these residents why they were needed to stay in their bedroom, and they described this as challenging and extra workload. There was additional workload for staff even when residents did remain in their rooms, as they talked of the time implications of taking meals and beverages into individual bedrooms as opposed to serving them all in the dining room, or ‘finding time to sit with them’ individually rather than sitting as a group in the lounge. Staff also had to regularly check on isolating residents to ensure they had not fallen and been unable to press their buzzers. Staff talked of the many negative implications that isolation could have on residents, including feelings of boredom, frustration, confusion and distress. Again, this was most prominent for those residents with dementia or cognitive impairment. Staff told us that some residents felt that isolation was a punishment and there were reports of residents ‘screaming’ or shouting out in exasperation, ‘Why can I not come out? I don’t want to be in this room’. Isolation affected residents’ mood and well-being, and they missed seeing their friends and expressed sorrow at the loss of their usual routines. Isolation also had severe, long-term impacts on a small number of residents, leading to physical decline or disturbing hallucinations:

‘One lady, she’s got Alzheimer’s and the isolation where they were all in their rooms and couldn’t go out, she’s forgotten how to stand up so now she is transferred by a hoist, which is really sad because she was walking before the pandemic’.

(Senior Care Lead)

Some residents also showed reluctance to come out of their rooms when their isolation period was over, as being in their rooms had become their new ‘norm’. Furthermore, staff acknowledged that isolation regulations could be very difficult for family members, who found it upsetting to know that their loved ones remained alone in their rooms. Yet, despite all these difficulties, there was an acknowledgement from some staff that isolating residents could be a successful way of controlling the spread of COVID-19:

‘… we did have someone come in with COVID and … touch wood that’s been our only case to date and we’ve gone a year, you know, we’ve gone a year now with that. So, I do believe our isolation works really well to protect the home and our residents and our staff’.

(Manager)

Staff highlighted several factors that could make isolation less difficult for residents. The most important of them was ensuring that they were suitably entertained with regular (socially distanced) visits from staff and various resources to occupy their time. Some CHs had created ‘activity boxes’ for isolating residents, including activities such as crosswords, colouring books, jigsaws, games and reading material. Some CHs gave isolating residents a radio, Echo or Alexa so that they could listen to music; an iPad or tablet so that they could contact loved ones (see ‘Visitor restrictions’ section); a TV to keep them entertained; and exercise equipment such as stretch bands, to keep active. All CHs also acknowledged the importance of staff sitting with the residents regularly to help prevent loneliness and playing games with them or providing ‘pamper sessions’ to improve their well-being:

‘… they can isolate, but they don’t have to feel isolated’.

(Senior Support Worker)

Staff did acknowledge, however, the importance of ensuring that any activities were tailored to the individual needs and interests of the residents and noted that some individuals were not interested in participating in such pastimes. Maintaining good communication with residents throughout their period of isolation was also identified as of crucial importance, with staff comforting residents, explaining the reasons why they needed to isolate and encouraging them to persevere. Some staff talked of the importance of maintaining a sense of humour and continuing to ‘banter’ with the residents to raise their spirits:

‘… the laughter and the sheer joy from everyone, that’s what I mean, it’s like friends, we’re a professional friendship, you know … you can’t buy that kind of care, you can’t buy that kind of communication, there’s no money in the world that could buy that. And that’s what you hold so dear to you and what we all needed to maintain at that time, and I think we did it. We did it’.

(Deputy Manager)

Having good teamwork and receiving support from managers and colleagues also made the experience of implementing isolation interventions easier for staff. Few staff talked of the isolation requirements for staff members, but those who did say that staff had to isolate when they were showing symptoms of COVID-19, had tested positive for COVID-19 or when they had returned from travelling abroad. Regular testing of CH staff had made it easier for them to identify when they needed to self-isolate.

Staff frequently talked about a range of other interventions, which had also been implemented within their CHs to prevent and control the spread of COVID-19. These are discussed below.

Restrictions

Staff talked in detail about a variety of restrictions placed upon CH residents, staff, family members and other professionals during the COVID-19 pandemic. Much of this was about changes to visiting. Staff talked to us about the consequences of severely restricted or controlled visiting both on themselves and others. We look at some of these restrictions in turn.

Restrictions on residents: trips outside the care home and mealtimes

Several different resident restrictions were implemented in CHs, but from the perspective of those staff interviewed, restrictions around residents leaving the CH and changes to the way food was prepared and delivered had made the most significant impact. A major restriction within CHs was to prevent residents from leaving the home. This included preventing them from visiting shops or other community settings and stopping them from using communal facilities within the CH, such as the gym or hairdresser. This was distressing for many residents, for whom such outings and facilities played an essential role in their daily life; we explore residents’ own experiences in more detail in Chapter 6. It was equally disappointing for staff, who also valued these opportunities for interaction with their residents:

‘… with my residents, we could go out before, we could go out for a pub lunch, we could go to a farm, you know, but we couldn’t do this anymore … That affects them, it affects us as well. We are locked in an environment for a month, a year, without seeing or doing things that we’re supposed to do, things that we like to do. And that was … so upsetting, that we couldn’t provide the best service that we could because of the pandemic’.

(HCA)

Being prevented from leaving the CH had many negative implications for residents’ mental health and well-being, with staff reporting that residents became ‘withdrawn’ and ‘introverted’. Even though many activities remained in place inside the CH, staff told us that residents missed their interactions with friends from outside (as well as friends from other households or on different floors of the home, whom they were no longer allowed to see). Some lost their enthusiasm to participate in activities:

‘… they don’t want to do anything … you ask some of them nicely, “Shall we do some activities?”, and they don’t want to, “I don’t want to play dominoes, I don’t want to do this”, because they’re getting that depressed, they’re getting very depressed’.

(Nurse)

In some instances, staff found that restrictions on leaving the home were more manageable for people with dementia (or those who did not regularly leave the CH before the COVID-19 pandemic), to accept. In comparison, staff told us that those residents who were previously active and enjoyed a busy social life outside of the home experienced the impact of these restrictions more severely (see Chapter 6 for residents’ own narration of this). Indeed, one resident complained to their social worker about the CH and the unwillingness of staff to let her continue visiting local shops and supermarkets. Several staff also commented on the effect that restricting residents from leaving the CH had on their physical health; namely their ability to get sufficient physical exercise. This was particularly notable in those CHs where residents did not have access to a garden:

‘For the whole year they’ve just been stuck in this space, in this one room. And it has impacted on … the walking side because they’re not getting the exercise on their legs. Their muscle strength is deteriorating because all they want to do is sit down all day’.

(Support Worker)

Staff reported that residents were thankful that restrictions had started to ease, and facilities were beginning to reopen for them again, albeit in a different way, such as the requirement to pre-book the use of the gym. Some felt that residents had become more appreciative of the facilities they had in the home and were now more inclined to use them than they had been pre-pandemic:

‘… even the gym, they’re quite happy. They’ve never bothered going, but now they think, “Oh, it’s a different room to go in, I’ve not been in this room before”, and they’ll go to there, yeah, because it’s a completely different room. […]. They’re even excited to go in the lift sometimes, they’ve not been in there for a whole year and, “Ooh, I’ve gone in a lift’, you know”’.

(Support Worker)

A second significant restriction for CH residents involved changing how their food was cooked and served. For example, in one CH, all meals had previously been freshly cooked in the household, so that residents could participate in preparing and cooking their own meals. This was initially stopped during the pandemic, with food cooked offsite and delivered to each household individually. Consequently, a couple of staff at this home had noticed that residents were not eating as well as they previously had, ‘because they weren’t getting the smells from the cooking’. Another CH was proud of their ‘fine dining’ facilities for residents and felt that the removal of this (due to the cleaning and sanitisation requirements associated with it) had been detrimental to the residents’ experience and in opposition to the ethos of the home:

‘You know, when you go to a restaurant and you see your knife, fork and spoon ready for you and you have a nice, you know, plant in the middle of the table and maybe like a candle and your salt and your pepper and your sauces, that all had to go, you know. So you’re just left there with bare tables and … it’s like a prison. It’s like a prison, the bare minimum, and that to us is totally against our nursing home culture because it’s not a prison, it’s their home and it’s just got all took away’.

(Deputy Manager)

Across several CHs, changes had also been made to where residents ate their meals, with examples provided of residents eating in their bedrooms or communal lounges being turned into temporary dining rooms to allow additional space for social distancing requirements. In some homes, such changes had been successful. For example, some ‘younger residents’ enjoyed eating their meals in the lounge away from the older residents. However, others did not appreciate the changes to their dining arrangements and found eating alone isolating, which could affect their appetite. These changes to where residents could eat their meals also had direct consequences on staff workloads, either because they needed to spend time with each resident who was eating alone or because they needed to spend more time cleaning and sanitising rooms and equipment where residents were eating together.

Finally, as many group activities were still ongoing within CHs throughout most of the pandemic (excluding periods of isolation), restrictions on group activities were believed to have had a lesser impact on residents. Indeed, many staff talked of the innovative ways in which they delivered new or alternative activities to their residents, such as ‘indoor gardening’ sessions for those who could not get outside, small group cake-making, yoga, karaoke, socially distanced bingo and quizzes, letter writing to local school children and online sessions connecting residents with local churches and community groups:

‘… we’ve had whale of a time … we have a right singsong. We’ve got a disco ball there that we put on, turn all the lights off, disco ball and we have a party down there most days’.

(Senior HCA)

Restrictions for families and friends

Families and friends had been restricted from entering all CHs early in the COVID-19 pandemic, and all staff discussed the implications of these restrictions. During the first lockdown, the government announced that there could be no visits from family and friends in any CHs (though some homes chose to instigate these restrictions before they became mandated by the government), and this was a considerable shock requiring major adjustments for residents, families and staff. In many instances, CH staff became a target of anger and frustration from residents and their family members, who could not comprehend that they were prevented from seeing each other. We explore family members’ own experiences of COVID-19-related measures and restrictions in Chapter 6. Here, we relate how staff talked about the impact on families and residents.

Staff felt that some residents blamed them for these restrictions and perceived them to be ‘bad people’, who were ‘keeping them here under duress’. Similarly, some families expressed extreme anger towards staff, and although staff could empathise with family members, these experiences could be frightening and upsetting for them. One staff member even said they had considered calling the police when relatives had become particularly confrontational and aggressive:

‘… we’ve had the relatives who’ve been very angry, they’ve turned up at the door of a care home demanding to be let in … and they need to see their loved one, demanding and shouting at the team’.

(Manager)

Staff reported how the introduction of restrictions had been distressing for many residents, and staff talked to us about how such conversations were difficult and affected staff too:

‘… it was very hard for one of my residents. Her daughter, she comes every week or twice a week, but when we tell them, “Sorry, no family members are allowed”, and she said, “Oh, if I don’t see my daughter I’m going to die”. “Oh”, I said, you know, those words are really heart-breaking for us as well’.

(Activities Co-ordinator)

Staff recognised some of the anxieties residents themselves felt (and which we explore in more detail in Chapter 6). They reported that residents told them they had been ‘abandoned’ or that their relatives chose not to visit them. Staff had had upsetting conversations with residents who expressed pain and anger towards their families. Missing ones’ family had negative implications for residents’ mood and mental health: staff noted that some residents were sleeping more throughout the day, while others had begun ‘talking to themselves because they’ve got no one … to talk to’. Other residents’ eating habits had changed because of their depression or because their family had not been there to support and encourage them to eat, and as such they had started to lose weight. Some staff suggested that visitor restrictions had been easier for residents with dementia, because they were less likely to remember that they had not seen their relatives. In contrast, the experience had been more upsetting for those who were aware of the restrictions:

‘… I know it sounds awful but sometimes people living with dementia who can’t remember their family are in their own world and you kind of think, I think I’d prefer to be in your world right now because they’re happy, they’re content and they don’t know any different and how awful is that. How awful is it to say that somebody who lacks mental capacity is in a better state of play’.

(Deputy Manager)

Indeed, there was the suggestion that some residents with dementia had found it more upsetting when family visits were reintroduced than they had when visitor restrictions had been in place:

‘We have noticed with several that now the visits are starting back up again we’ve got more behaviours and more distress behaviour than we’ve had for the last year because they’ve just been so comfortable and settled with what’s happened’.

(Deputy Manager)

Staff also noted that deeper friendships had grown between residents and staff during periods of visitor restrictions. Staff had learnt more about their residents and their individual likes and needs. Some staff had told residents that they were their ‘family’ during the period of restrictions, and this had offered residents some comfort:

‘… we used to sit with them and say, “Look, here you go, we are a big family here, you’ve got family outside but you’re our family now, you’re our family, we’re here for you if you need anything”’.

(Senior Care Worker)

Some staff felt that the restrictions were even more distressing for family members than for residents, with many relatives feeling concerned about their loved ones and anxious about what they were hearing on the news around COVID-19 in CHs. There were reports of ‘a lot of stress and a lot of worry’ from relatives, as well as sadness and ‘missing happy times’. Some relatives experienced difficulties with the ‘lack of control’ they had over the situation, particularly those who regularly helped residents with personal care and many expressed guilt that they could no longer be there for their loved one in the ways they previously had:

‘… I was talking to a family member the other day and he was saying that “I feel like the staff have taken on my role”, and he said, “And I felt really bad and really guilty about that” […] and he said, “I was worried that I’d let her down and that I’d failed her”’.

(Nurse)

Staff, therefore, had to navigate this complex emotional terrain of the guilt, envy and loss experienced by family members. Family restrictions were particularly difficult in EoL situations, where family members could not see their relatives before they died. Some staff also reported significant trauma associated with residents being prevented from having their loved ones around them at the time of their death:

‘… and people died, with no family, just us. As a nurse, as a human being, and also somebody who’s lost their own father, I found that really, really hard [gets upset]. I had many nights I couldn’t sleep, “Had I done the right thing?” I had, I’d managed to keep COVID out of the home, but that’s hard’.

(Manager)

‘There was a gentleman that was passing away, that his brothers asked me not to let him die on his own. So that’s what I did, and sat with him and spoke to him […] it’s only now talking about it that I actually, like, realise it as well. It kind of gets locked away’.

(Lead Nurse)

Although all CHs had allowed relatives to visit their dying loved ones during at least some parts of the pandemic, these visits had still had restrictions in place, such as a screen between the resident and family; restrictions on touching; the use of masks and other PPE equipment; and limits on the number of family members who could visit:

‘… there’s no sitting there holding their hand and the usual stuff that they would do, and it is, it is a bit heart breaking to watch, you know, a socially distanced end-of-life visit … it just seems so impersonal, so uncaring, even though, you know, it’s the guidelines, it’s the law … it’s just not right at all’.

(Senior Care Assistant)

Staff were very concerned about the welfare of relatives, particularly those who were elderly themselves. They also expressed their own guilt around not being able to revoke the visitor restrictions or ease the pains experienced by family members. Preventing residents from seeing their relatives went against the caring instincts of staff and they felt distressed at seeing relatives so upset and being unable to help them as ‘we can’t break the protocols’:

‘… I’ve hated every single moment of it when I’ve had to say, “You can’t come in” […] and I’ve wanted nothing more than to just open the door and go, “Go on, go and see your mum.” I really, really have’.

(Deputy Manager)

However, staff felt that, overall, most relatives did understand why the restrictions were in place and were supportive and grateful to staff for caring for their loved ones in their absence. Many also believed that these restrictions had been beneficial for controlling the spread of COVID-19 in the CH. Finally, staff reported that visitor restrictions had significantly increased their workload. Many staff talked about considerable increases in the number of telephone calls CHs were getting from relatives every day and the impact this had upon them, as well as the additional time they had to spend feeding back updates on residents to their relatives:

‘… the phone calls, even at home I would get home and I could hear the phone call ringing, and I had insomnia for weeks, for weeks insomnia, I couldn’t sleep … they are not working in these environments, they do not understand the pressure, to do medication, to do safe medication administration … it is a high amount of pressure to have that, and the phone ringing constantly distracting you’.

(Senior Nurse)

Extra staff time was also spent supporting residents, explaining why they could not see their loved ones and ensuring they were well entertained in their relatives’ absence. While these visitor restrictions were in place, all CHs in this study had attempted to help residents maintain contact with their families using telephone and video-calling (using Skype or Zoom etc.), and this had been incredibly beneficial for many residents and helped raise their morale. However, telephone or video calls were not suitable for all residents. Those who had dementia, vision/hearing problems or those who were not comfortable using technology had struggled to experience the benefit. Similarly, not all staff members and relatives felt comfortable using new technology, not all CHs had good Wi-Fi access, and some family members did not have their own telephone or computer on which to receive the calls. Furthermore, many residents needed assistance in using this technology and required staff to stay with them when making their calls, which meant extra workload for staff and a lack of privacy for residents and families during their conversations. Some CHs also had to buy additional equipment to accommodate these calls, which had financial implications.

Care homes also initiated a variety of additional creative ways for residents to see their family members. These included ‘drive-by’ visits, ‘window visits’ and outdoor visiting ‘pods’. One CH installed a new telephone line purely for family enquiries, which eased much of the congestion on the main phone line. Others made internal changes to their buildings, such as installing glass screens in visitor rooms and increasing the number of entrances and exits. However, even when families were able to enter the CHs again, several visiting restrictions remained in place, such as limits on the number of visitors, and the duration and regularity of visits. Family members had to pre-book appointment times and were required to be tested for COVID-19 before entering the CH. There were discrepancies reported around whether residents and families were able to hug each other during visits, with some staff saying this was now permitted and others saying it was not. All these restrictions added a layer of time and complexity to the visiting arrangements and increased staff workload. Furthermore, a few examples were provided of families refusing to abide by the restrictions, meaning that staff felt they needed to ‘police’ some of the visits. Staff also felt uncomfortable and upset that they needed to address issues of breaking restriction rules with family members.

Several factors were identified by staff as helping to make the difficult period of visitor restrictions more bearable for themselves, their residents and family members. These included maintaining good communication with relatives (including holding regular online meetings for families where they could air their concerns) and receiving good support and guidance at a senior management/company level. Having a building layout where all bedrooms had exterior doors was also felt to be beneficial, as this allowed family members to visit their relatives without entering any other part of the CH.

Restrictions for care home staff (e.g. changes to working patterns, shifts and rotas)

Restrictions for CH staff were discussed less frequently than those for residents and families. A few staff members said their working arrangements had not noticeably changed because of the COVID-19 pandemic. However, other staff were able to identify several ways in which their working lives had changed. For example, some participants reported changes to shift lengths and rota patterns in almost all CHs, with staff working longer shifts or overtime, being on ‘standby’ or working through their annual leave. Managers had to plan rotas carefully, due to staffing issues associated with increased staff sickness, ‘shielding’ staff, staff leaving their roles due to fears of working during the pandemic or staff being furloughed. They also had to consider the individual circumstances of their staff (such as childcare issues, which might prevent them from working certain hours). Managers’ workloads further increased due to the regular phone calls and complaints from residents’ families and increased communication with external organisations such as the CQC, who regularly phoned for updates. Indeed, in some homes, managerial staff said they had (or had been prepared) to stay the night in the CH should the need arise:

‘… we all packed our bags. I’ve still got it in the boot of my car, I’ve got a blow-up bed and an overnight bag with about 4 days’ worth of supplies just in case, because you could never anticipate what could happen’.

(Deputy Manager)

Several examples were provided of staff ‘upskilling’, switching roles (e.g. moving from the role of ‘well-being co-ordinator’ to ‘care worker’), or taking on aspects of another’s role during the pandemic. Indeed, one nurse described the situation in CHs as being ‘all hands on deck’:

‘I had to upskill the team, because if staff suddenly went ill and I’ve got no team who would care for my residents? […] admin, housekeepers, maintenance were all upskilled to be able to go on floors, serve meals, give drinks, support us getting residents in and out of bed’.

(Manager)

In a few instances, staff had been restricted to working on one floor/household or working with the same small cohort of staff and residents. While these arrangements were believed to help limit the spread of COVID-19, some staff found these restrictions difficult, as they inhibited their ability to communicate more widely with residents and other staff. In one home, staff were asked to only work within that setting and to not work shifts elsewhere. The manager at this home said staff were contented with this restriction, as they felt it helped protect their own safety, and the safety of the other staff and residents. The manager also ensured staff who would ordinarily work elsewhere were given extra shifts in the home so that they did not suffer financially. The use of agency staff differed across CHs, with one manager stating that they stopped using agency staff altogether while others said they did employ agency staff when there were staffing constraints. However, this was implemented in a limited way (e.g. only using one agency, ensuring agency staff did not work within any other CHs and that they were regularly tested for COVID-19). One CH had to reduce the number of staff working due to the closure of one floor in the home, but another had to recruit additional staff, which had financial implications for the home.

Despite the restrictions placed upon staff, several people were able to identify positive outcomes of their experience of working during the pandemic. There was a suggestion that the experience had brought staff ‘closer together’, had helped encourage better team working and gave staff a greater ‘appreciation’ of the roles of their colleagues. However, there was also a suggestion that adapting to new ways of working during the pandemic had been ‘exhausting’ for some staff. An important factor that helped during periods of staff restrictions was receiving good managerial support. Some staff spoke effusively around their gratitude for their CH managers, whom they described as supportive, available and willing to have open and honest conversations with their staff, listening to their suggestions and taking on board their feedback. Good managers were also seen to boost the morale of their staff, give them the motivation to continue with their work during difficult periods and reward them with little treats. Having a manager who encouraged staff to take regular breaks while working (something that was not always possible due to heightened workloads) and to use their annual leave where possible was also appreciated.

Restrictions for healthcare professionals and other visitors

In addition to restricting families and friends from entering CHs, restrictions were extended to all external healthcare and non-healthcare professionals and other visitors. This prevented anyone who would ordinarily go into a CH from entering, including GPs, physiotherapists, occupational therapists, mental health teams, social workers, clergy members, hairdressers, entertainers, activity staff and school children. These restrictions on external visitors led to additional workloads for CH staff:

‘…. now we’re hairdressers, we’re counsellors, we’re advocates, we’re social workers, we’re doctors, you know, everything, we’re everything’.

(Lead Nurse)

Some staff reported that district nurses could still enter the home (though there was sometimes a long wait for such services), and some said that GPs would still visit in person in the case of an emergency. However, communication with all external visitors was conducted online or over the telephone in most cases. Staff believed the greatest impact came from communicating with healthcare professionals remotely, particularly GPs, as some questioned whether healthcare assessments could be successfully carried out online. A few staff said that extra pressure had been placed upon them by not having GPs and other healthcare professionals visit the home in person. They felt this resulted in them having to make quick clinical decisions about a resident or ensuring that they provided external healthcare professionals with all the necessary information about a resident to make an informed decision. This could be worrying for some staff, who could begin to doubt their ability to give information appropriately or ask the right questions. Others felt they were being asked to complete tasks ordinarily undertaken by other healthcare professionals, which they were unqualified to do, and this made them feel nervous and unsupported:

‘… we didn’t know if we were doing things wrong with, like, the exercises and stuff from the OT perspective, and even for like SALT reviews, we’re having to monitor them when we ain’t professional in that background. So, it was quite scary, but yeah, we managed it’.

(Deputy Manager)

However, this deputy manager believed that CH nurses were well placed to work in this way, as they knew their residents well and were able to identify when they were becoming unwell. They also believed CH nurses were accustomed to working independently in the community and were comfortable with trusting their instincts. There were few examples of the implications of these restrictions on residents, though one manager did highlight a couple of residents who had been negatively affected by delays in their care because of healthcare visitor restrictions:

‘I think one of our residents had a really bad toe … under the normal circumstances, a GP would have looked at that, referred him to the foot clinic or a podiatrist and they would have probably removed the nail. But he had to go through sort of like weeks and weeks of pain until the toenail actually fell off, you know. That was one of them but there’s been other things as well. Like a pressure sore, you know, it’s tiny and we’re looking after it but then all of a sudden it sort of like becomes red, so the district nurses, you don’t see them for absolutely ages and then it’s too late and then that pressure sore then becomes … a graded pressure sore’.

(Manager)

Slowly, such restrictions were beginning to be eased within CHs, with healthcare professionals being able to re-enter the homes again. However, there were reports that some healthcare professionals had still not returned to face-to-face appointments, which was disappointing and confusing to some CH staff.

Zoning and cohorting

One CH highlighted an example of ‘zoning’ by treating each household as a separate subgroup. When there was a confirmed case of COVID-19, that resident’s whole household was required to isolate, but the rest of the village was not. Interviewees provided a few other examples of zoning. One care assistant said they disagreed with the idea of zoning residents if this involved moving them on to different floors, as the residents would find this ‘destabilising’. One deputy manager said they had discussed and prepared for the possibility of creating a unit specifically for residents with COVID-19. However, staff had discord about these plans, with some individuals stating they would refuse to work on this unit. Fortunately, these plans did not have to be initiated, as none of the residents contracted COVID-19. One CH did not ‘zone’ their residents but did use a form of cohorting, whereby residents were clustered into small groups and allocated one staff member per shift to attend to their care needs. The reasoning for this was limiting the number of contacts each resident had each day to help reduce ‘cross-contamination’. One senior HCA, however, expressed concerns that while this approach could be helpful in the pandemic, it could have negative repercussions in the longer term:

‘… I do feel that doing it that system, certain carers don’t get to care for other residents, they’re not getting the full view. So when this pandemic is over and we may go back to our old way … they’re not going to know what their care needs are, so it’s going to be like they’re learning from scratch again, a whole new bunch of residents. It’s really going to be difficult because they’ve only concentrated on certain residents while they’ve been on shift, which has been good from the pandemic point of view, but from a care point of view they’ve isolated themselves from all of the other residents’.

(Senior HCA)

Surveillance: the effects of regular testing

Some staff talked about the surveillance measures implemented within CHs during the COVID-19 outbreak. These were the same as infection control measures implemented for other infectious diseases and included being aware of the signs and symptoms of COVID-19 in residents and staff. At the start of the pandemic, residents had daily checks on their temperature and oxygen saturation and regular observations for any COVID-19 symptoms (e.g. cough). Any concerns were quickly escalated to the CH manager and GP. Some staff also said they checked their temperature before starting each shift. However, the implementation of new testing regimes had been beneficial for CH staff in identifying cases of COVID-19 more rapidly. Following government guidance, CH staff were now taking regular lateral flow, and PCR tests and residents were also tested regularly (usually monthly) and isolated when positive results were returned. Visitors were also required to take LFTs at the CH before entering the premises. This had proved significant in some instances, where visitors with a positive test result had been identified and turned away before entering the home. Some staff said the testing requirements made them feel less anxious about going to work and had made the atmosphere in the CHs more relaxed:

‘… it gives you that peace of mind that yes you’re safe, everyone is safe, you can carry on with your job’.

(Senior Nurse)

However, the testing process had also resulted in increased workload for staff, as undertaking the testing and then recording the results of these tests onto the computer system had been added as an additional task in their weekly routines. For example, some of those administering the tests spoke of having to ‘chase’ staff to get their tests done. All visitors also had to take a LFT at the CH and then wait for 30 minutes outside before entering the premises, and staff said this added a layer of complexity to their workload. For example, one senior HCA said they had to set a 30-minute alarm after each test had been completed to remind them to go and tell the visitor if they could enter the home. They, therefore, stated, ‘I’ve got alarms going off all day in my little room!’. Several staff also commented that they needed to cope with the anger and frustration of some visitors, who could not understand why they had to wait for 30 minutes before they were allowed to enter the home. Some CHs had secured infection control funding, which had enabled them to recruit a member of staff to focus only on the testing process, but this had not been the case for all CHs:

‘… it is just never-ending from the test point of view, putting those on, working to the deadlines, remembering to do things like order your test collections because you can’t do them too far in advance … You sort of think ‘Oh no, do you know how much work is involved in that?’ And then they brought in the lateral flow tests, so we’ve now got two of those for every member of staff to register, and just when you’ve got on top of doing those they then say “Right, we’re going to bring relatives back in now, they’re going to have to be lateral flowed as well”, so another load to put in’.

(Deputy Manager)

Some staff also discussed the COVID-19 vaccine and felt that vaccinating residents and staff had helped increase their safety. However, there were reports that some staff questioned why they needed to have the vaccine or why – when they and their residents were fully vaccinated – they still needed to continue with infection control measures:

‘… why now we’ve had two vaccines, why now are we having three tests a week, one PCR and two lateral flow tests, are we still having to wear masks? Why are we now having to wear visors? You know, it was all kind of, it wasn’t ever promised, but it was almost like, “We’ll have all this, do all this, and then we’ll kind of get back to normal”’.

(Manager)