Decision details

Councillor Alison Born introduced this item to the Panel. She explained that this report follows on from the interim report that had been previously submitted to the Panel that looked at a wider section of data regarding the pandemic and showed that whilst there was a higher than expected number of deaths within Care Homes, there was a low number of deaths within hospitals from Covid-19.

She said that this was a pattern that had been in place for some time locally with many people choosing for their end-of-life care to be with their own home or place of residence.

She said that a decision was taken to ask for an independent review to be undertaken to look at more detailed local data, and also qualitative data by speaking to people who had been working in the Care Homes during the pandemic. She added that she did not feel that any large concerns had been identified in the report, but that it does give an insight into what it was like at the time and what points can be learned in preparation for any such events in the future.

Theresa Redaniel addressed the Panel and shared some presentation slides. These slides will be attached as an online appendix to these minutes, a summary is set out below.

What is an Applied Research Collaboration or ARC?

·  Funded by the National Institute for Health and Care Research (NIHR), the nation’s largest funder of health and care research.

·  ARCs support applied health and care research that responds to the needs of local populations and health and care systems.

·  NIHR ARC West is one of 15 ARCs across England, part of a £135 million investment by the NIHR over five years.

·  Collaborations of local partners, including providers of NHS and care services, commissioners, local authorities, universities, companies and charities.

·  The research is done in collaboration with the partners as well as the public and communities.

What is applied research?

·  Applied health research aims to address the immediate issues facing the health and social care system.

·  ARC researchers do research that addresses the needs of the health and care system, the people who use services and other communities.

The research problem

·  Impact of COVID in care homes – cases 13 times higher than in the community.

·  Vulnerable population – higher risk of death & high number of deaths in care homes.

·  High death rates in care homes in B&NES – in comparison with similar areas.

The research aims

·  Determine why B&NES appears to have higher death rates from COVID in care homes compared to other locations.

·  Whether there are specific risk factors associated with COVID-19 infections and deaths in care-homes within B&NES.

·  To examine what learning from the first and second wave of the pandemic can be used to improve policy and practice.

Study design

·  Quantitative 

o  Risk factors for high COVID infection rates/death, e.g.

§  Care home size / Care home type / Care home ownership / Engagement with B&NES Council / Plus eight others

o  Care-home level data supplied by B&NES (Second COVID wave)

o  Association between risk factors and infection/death rates

• Qualitative

o  Semi-structured interviews with care home staff

o  Sample of care homes of different sizes/types

o  Participants and data to be fully anonymised in reports.

o  Presented as documenting experience to learn rather than an audit of practice.

o  Draw on findings from the quantitative research to explore in detail.

Challenges

·  Quantitative 

o  Data quantity

o  Small number of care homes in the sample

o  Only covers a limited period (Sept 2020 – Feb 2021) 

o  No data from comparator areas

Data quality 

o  Only data at care home level is available.

o  Not data on variables such as actual number of residents in the care homes, use of agency staff, vaccination status, staff infection rates or staff working across different sites.

·  Qualitative 

o  Care home recruitment.

o  Staff shortages – research not prioritised.

o  Staff changes - managers and staff in post during pandemic moved on.

Study design change

o  Recruit outside B&NES WHY?

o  Interviews in B&NES - interesting and valuable data but B&NES recruitment stalled - data spoke to issues within and beyond B&NES

o  Decision to build on these data and recruit across ARC West patch.

o  Inform and reflect on management of COVID in care homes in general.

Jon Banks addressed the Panel on the following section of the presentation.

Results – Quantitative

·  33 care homes included in analysis (Sept 2020 – Feb 2021)

·  Total 290 COVID-19 cases 

·  Average weekly cases = 0.35 (range 0-16) / Average age was 85 years / 71% female 

·  Total 101 COVID-related deaths 

·  Average weekly deaths = 0.12 (range 0-6) / Average age was 89 years / 64% female

COVID-19 cases

·  Medium and large care homes were at greater risk.

·  Managers in post for less than a year were associated with fewer cases.

Results – Qualitative

·  Recruitment and analysis

·  5 care homes

·  14 interviews (managers and support staff)

·  Data analysed thematically.

·  Key themes – focus on

·  Infection prevention & control policies

·  Guidance and legislation

·  Relationships with outside bodies (local authorities and health services)

·  The psycho-social aspects of lockdown

·  Reorientation of practice

Note – data presented represent participants’ views and experiences rather than an audit of practice or behaviour – a reflection of how staff in care homes saw and experienced the pandemic.

Jon Banks shared a series of quotes with the Panel that had been gathered as part of the study.

Summary and learning

Results indicate …

·  Care homes practices & behaviour did not contribute to the B&NES pandemic death rates.

·  Staffing shortages - biggest challenge.

·  Building layout and structure mitigated against resident isolation policies.

·  Looking forward - More autonomy to balance infection control and psychosocial wellbeing.

·  Support and maintain lines of communication.

o  Reduce feelings of care homes feeling abandoned.

o  Reduce confusion caused by multiple sources of information.

Kevin Burnett referred to section 3.15 of the covering report and asked who was responsible for taking these learning points forward.

The Associate Director for Public Health replied that these points have been shared with colleagues in Adult Social Care and it will be for them to take forward as part of future work around infection control / pandemic planning.

The Director of Adult Social Care added that they could provide an update as part of the Transformation Programme in September.

Jon Banks said that the study would also be published in a policy making journal to feed into policy at a wider level.

Kevin Burnett asked how the Care Homes and the ICB are involved in taking this work forward.

The Director of Adult Social Care replied that they meet with all Care Homes on a regular basis and discuss issues relating to culture, leadership and infection control. She said that they have a joint approach to this work with the ICB who also take part in visiting them alongside a colleague from the Council.

Kevin Burnett asked if any degree of autonomy could be given to Care Homes in the future with regard to procedures to follow in future pandemics.

The Director of Adult Social Care replied that this would be difficult as all homes are inspected and governed by the CQC and therefore not many factors would be within our gift.

She added that B&NES was in a good position regarding the range of Care Homes that are available in the area with 77% rated as either good or outstanding. She said that a significant amount of leadership and co-production is carried out with the residents.

Councillor Born added said that the issues relating to isolation -v- social cost and the guidelines that were set down by central government should be analysed as part of the Covid Inquiry and consideration given as to whether they could be more balanced in the future.

Kevin Burnett asked if individual Care Home plans were required.

The Director of Adult Social Care replied that the Council has provided information to the Covid Inquiry and said that there was a standard approach that was adopted for visitors and regarding PPE that would be difficult to go against if this was again advised nationally.

The Director of Public Health stated that all Local Authorities have been approached to provide feedback into the Covid Inquiry. She added that during the pandemic staff followed the national guidance and worked as collaboratively as possible with Care Home managers to put that into practice.

Councillor Liz Hardman asked if following the research that has taken place, is there a plan in place for future pandemics that will protect the residents and staff in our Care Homes.

The Associate Director for Public Health replied that the pattern of a high percentage of Care Home deaths and low percentage of hospital deaths has been in place for around the past 10 years. He added that the percentage of deaths in hospital was decreasing year on year which he suspected was due to more individual care planning being in place.

He informed the Panel that B&NES has a low rate of hospital admissions from Care Homes when compared to other Councils.

Councillor Hardman asked whether the scenario of patients being discharged from hospital into Care Homes had been a factor in the figures locally.

The Associate Director for Public Health replied that no association with this scenario had been found in the study.

The Director of Public Health added that they would be learning from the national Covid Inquiry to inform future planning. She added that at a local level, reviews have taken place and a document has been produced entitled ‘Living safely and fairly with Covid’.

She said that work has also been done to plan on how such a similar event would be escalated, but a lot would depend on a national plan including access to testing, PPE and funding for those who have to self-isolate.

Councillor Paul Crossley asked if any action was recommended if any outliers were identified during the course of the study.

Jon Banks replied that 5 Care Homes were involved in the study and that no exceptional information had been identified. He added that it was also not within their remit to take such action.

Councillor Crossley asked if there had been any refusal to take part in the study.

Jon Banks replied that the Care Homes that took part were invited to do so after expressing an interest and that there was no pressure to do so.

Councillor Crossley asked if any lessons could be taken from the study regarding social isolation.

Jon Banks replied that the study has been able to give a voice to staff on how they perceived the impact of the pandemic. He added that consideration needs to be given to how we approach further incidents of this nature.

Paul Scott added that this study and other pieces of work need to be reflected upon and the impact such as decisions regarding keeping children away from school have had, whilst recognising the need to keep people as safe as possible.

Councillor Crossley commented that it was felt that as a country we were two weeks late in taking information about the virus seriously and asked if there was a guide now for how we should be prepared for another such event.

The Director of Public Health replied that guidance is expected following the conclusion of the national inquiry and that examples of good practice have already been established.

Councillor Crossley how was it possible for there to be contradictory advice being given when there were nightly broadcasts regarding the latest available information.

The Director of Public Health replied that elements such as this were again expected to be addressed within the national inquiry. She said that she felt that messages and guidance became clearer the longer the pandemic lasted.

She added that specific advice relating to Care Homes was not given initially with the focus being on general infection control and prevention. She said that it was important for information and messages to be agreed corporately so that all departments / sectors, including Public Health and Adult Social Care, are aligned.

Councillor Wright commented that she found the quotes within the report to be powerful and recalled at the time a case of a resident moving to be near a relative living in a Care Home and was then not able to see them and the lasting impact that this has had on them. She said that instances like this should not happen again.

Jon Banks said that ARC West want to see changes following their research and intend to do their upmost to make sure our work has an impact on future policies.

Councillor Wright commented that the matter of excess deaths locally was still to be fully understood. She said that it was recognised that the public needs to be protected when another similar event occurs, but queried the balancing factors between the financial cost -v- emotional cost as she believed that pain within communities still exists following the pandemic.

The Director of Adult Social Care said that the staff now working within our Care Homes are experts in infection control and that as a department they will work with Public Health on how to progress with these findings. She added that she would like to take this opportunity to thank all those who have and continue to work in our Care Homes for all their work, especially under such circumstances during the pandemic.

Councillor Mansell asked if the study took account of whether staff moved between hospitals and care homes and whether that had any impact. She added that there needs to be consistency over advice for whenever another such event occurs.

Theresa Redaniel replied that they did not have access to hospital staff data as part of the study.

The Associate Director for Public Health added that data relating to agency staff was also not available for the study.

Councillor Malloy asked if the overall age of Care Home residents was considered as a contributing factor locally.

The Associate Director for Public Health replied that we do know that within B&NES we have a higher percentage of nursing home beds per head of population than residential beds and that could be seen as a factor in the number of deaths that occurred.

Councillor Hardman said that she would like to suggest a recommendation 2.3 that seeks to adopt the learning points that were listed within the covering report at section 3.15.

i)  Staffing shortages was the biggest challenge identified by the care home staff. This is an ongoing issue with no clear answer. However, we would urge policy makers at government and local authority level to develop contingency plans that will enable care homes to be supported with emergency staff cover for pandemics and other unexpected events.

ii)  Isolation and infection control: building layout and structure mitigated against some of the recommended policies for isolating infected residents. In partnership with local authorities care homes could develop and regularly update infection and prevention control plans that are particular to their setting.

iii)  More consideration and autonomy could be given to care homes to enable them to find the right balance between infection control measures and the psychosocial wellbeing of their residents. There was a strong feeling that the measures imposed to support infection control went too far in removing the social aspects of resident’s lives, especially in homes with a significant proportion of people living with dementia.

iv)  A key aspect to diminish the feelings of abandonment and isolation is to support and maintain lines of communication especially around policy and guidance where multiple sources of information led to confusion and uncertainty.

v)  Thank ARC West for their report and the staff within our Care Homes and their respective families for all their work, effort, commitment and sacrifice during the pandemic.

vi)  These recommendations are to be considered alongside any findings and actions that are proposed following the conclusion of the national Covid inquiry.

vii)  The Panel requests an update report to their September meeting on the implementation of these recommendations.

These recommendations were seconded by Councillor Crossley.

The Panel RESOLVED unanimously to note the findings of the work undertaken by NIHR ARC West, as well as the previous analysis brought to PDS in 2023 and to approve the recommendations set out above from Councillor Hardman.