Relevance of this setting for outbreak prevention and control
Nationally, approximately 400,000 older people in the UK live in care homes. This is a bed base three times that of the acute hospital sector.
Most care home residents have some degree of cognitive impairment, multiple health conditions and physical dependency and many are in their last years of life. Many care home residents are particularly vulnerable to COVID-19 infection as a consequence of their complex medical problems and advanced frailty, and due to regular close contact with staff providing social, care and nursing support. Their vulnerability leads them to be particularly susceptible to infection with an increased likelihood of poor health outcomes and death.
As with other settings, robust, continuous and well-planned approaches to infection prevention and control can make significant differences which can reduce rates of infection. Key concerns relate to transmission between residents, and between residents, the staff who support and care for them and visiting friends and family.
Care homes in B&NES include both nursing and residential provision with significant specialist provision for those with dementia, complex needs, learning disabilities, autism or mental health needs. The majority of residents are from the B&NES area. Care homes are run in the main by private businesses (18 separate companies) with 3 charitable/not for profit homes running 4 homes. Specialist homes (mental health and learning disabilities/autism) are run by 12 businesses.
|Type of care home||Number of homes||Approx number of residents||Approx number of staff|
|Type of specialist home||Number of homes||Total bed space||Approx number of staff|
|Learning disability/autism - residential||21||196|
|Learning disability/autism - nursing||1||15|
Responsibilities of the LA to providers
The LA has both direct and indirect responsibilities to support providers. Beyond COVID-19 support the LA retains ongoing responsibilities through the Care Act 2014 to maintain and support a market that delivers a wide range of sustainable, safe and high quality care and support services. The contract held by the LA and CCG commissioners with care homes includes expectations on infection prevention and control practice.
In B&NES much support is given through an integrated arrangement through the Council, Clinical Commissioning Group (B&NES, Swindon and Wiltshire) and Virgin Care. The journey towards closer integration is set out within the Your Care Your Way programme, redesigning community health and care services and consolidating the commitment to invest in preventative services and to further develop integrated services with Virgin Care. Developing this integrated model has enabled B&NES to respond to the challenge of COVID-19 with well-coordinated support and has furthered commitments to increasing the speed of acute to community discharge.
It is important to note that the Council has been particularly impacted by the COVID-19 experience, having seen significant loss of income consequential to its role as a national heritage site. Savings will need to go beyond efficiency and on-going commitments to manage care costs.
A number of teams and organisations work with care homes to help homes prevent and manage cases of COVID-19 including the Adult Social Care commissioning team, GP practice, CQC, LA public health team, IP&C officers, community frailty practitioner, and the CCG IP&C lead.
Outbreak management plan for care homes
Possible case: Any resident or staff with symptoms of COVID-19 (fever, new continuous cough, loss of normal sense of smell or taste, new onset of influenza like illness or worsening shortness of breath). Note: elderly people can often present with non-typical symptoms such as sudden decline in physical or mental ability, lethargy or change from usual demeanour without other explanation.
Confirmed case: Any resident or staff with laboratory confirmed diagnosis of COVID-19.
Resident contacts are those that:
- Live in the same unit / floor as the infectious case (e.g. share the same communal areas), or
- Have spent more than 15 minutes within 2 metres of an infectious case.
Staff contacts: care home staff that have provided care within 2 metres to a possible or confirmed case of COVID-19 for more than 15 minutes.
Two or more cases which meet the case definition of a possible or confirmed case as above, within a 14-day period among either residents or staff in the setting.
Monitoring arrangements and the flow of test results
Critical to identifying localised outbreaks is the ability to access very timely data, preferably within 24 hours or sooner of a suspected case being identified. Cases in residents and staff are identified in several ways.
The following section sets out the processes by which details of possible and confirmed cases are fed into the NHS Test and Trace system, and by which the LA is notified of such cases.
The Health Protection Team's (HPT) Standard Operating Procedure for care homes sets out that care homes will notify the HPT of:
- a single suspected or confirmed case of COVID-19 in a resident (the HPT then arrange testing and give IPC advice).
- suspected outbreak of COVID-19 in the care home (the HPT then arrange testing and give outbreak control advice).
- more than 1 staff member off sick with symptoms of COVID-19 OR 1 staff member laboratory confirmed with COVID-19.
In addition to the above, all care homes have been encouraged to take up the national ‘whole care home testing’ programme which enables testing for all residents (whether or not they have symptoms) and asymptomatic staff and the HPT are notified of any positive cases.
Symptomatic staff access testing through national self-referral or employer referral portals. The HPT are then informed of confirmed cases through the national NHS Test and Trace system and will carry out contact tracing with these cases.
The pathways by which local authorities receive data on possible or confirmed cases are developing all the time. At present, the local authority is made aware of possible/confirmed cases through the following routes:
- Notification from the Health Protection Team of possible or confirmed cases reported to them by care homes.
- Notification from the Health Protection Team of confirmed cases identified through the Whole Care Home Testing scheme.
- Numbers of COVID-19 possible/confirmed cases and deaths as reported by care homes to Adult Social Care daily (includes numbers of positive and negative results reported through Whole Care Home Testing).
- Daily line lists received about confirmed cases in B&NES providing information on age group, gender, MSOA.
- Weekly line list received on confirmed cases in B&NES providing information on age, gender, and postcode (postcode usually identifies the care home).
The following tables give an overview of the multi-disciplinary response to different case and outbreak scenarios in care homes. A more detailed care home outbreak management development plan will be produced to sit behind this.
No suspected or confirmed cases (prevention)
|Commissioner||Offer support & advice on range of issues. Gather daily sitreps from care homes. Disseminate materials on prevention and comms guidance. Encourage take up of learning and testing opportunities. Facilitate PPE access. Seek assurance on preparation for dealing with positive cases. Co-chair regular IP&C MDT meetings to identify support needs of identified care homes.|
|LA Public Health/Comms||Plan for strengthened IP&C. Localise & disseminate prevention and comms guidance. Encourage take up of learning and testing opportunities. Seek assurance on preparation for dealing with cases. Support PPE access. Develop risk assessment. Co-chair regular IP&C MDT meetings to identify support needs of identified care homes.|
|LA Infection Prevention and Control Officer||Maintain contact with care homes providing training, advice, problem solving. Follow up actions from IP&C MDT meetings with identified care homes.|
|PHE Health Protection Team||Develop guidance and prevention materials and encourage take up of learning opportunities.|
|BSW CCG||Plan for strengthened IP&C.|
First report of one or more possible/confirmed cases
|Commissioner||As above. Encourage reporting to HPT.|
|LA Public Health/Comms||As above|
|LA Infection Prevention and Control Officer||Contact care home to offer support and draw in wider input as needed.|
|PHE Health Protection Team||Follow national standard operating procedure. Notify LA.|
Escalation of cases and/or deaths
|Commissioner||Contribute to outbreak control meetings. Offer mental health support as needed in collaboration with AWP.|
|LA Public Health/Comms||Contribute to/lead outbreak control meetings.|
|LA Infection Prevention and Control Officer||Contribute to outbreak control meetings.|
|PHE Health Protection Team||Follow national standard operating procedure. Notify LA and consider holding outbreak control meeting in collaboration with LA PH.|
|LA Environmental Health team||Contribute to contact tracing as required.|
|BSW CCG||Contribute to outbreak control meetings. IP&C lead to visit home to review IP&C processes and offer support.|