Coronavirus (COVID-19) – Frequently Asked Questions – Social Care

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This detailed, extended blog post will look at frequently asked questions about social care in relation to coronavirus (COVID-19). Guidance and information in this area are rapidly being updated, so this blogpost will be updated as necessary. For ease of navigation, links below will take you to the relevant section of the blog. It is organised by topic:

What are the differences between the NHS and social care?

Since the advent of the pandemic, social care and health have been discussed as if a unified entity. While Scotland might be on the path to realise that goal, the two are not yet fully integrated.

Social care staff, along with NHS staff, have been clearly identified as key workers from the outset.

However, social care is a bigger umbrella than the NHS in terms of structures and complexity. This means that the pandemic has affected planning and delivery of care services in very different ways. There is no single co-ordinating body for social care as there is for the NHS in Scotland.

Services are delivered by private and voluntary sector providers as well as local authorities, health and social care partnerships (HSCPs) and NHS Boards. They all might run/own care homes, day care services and/or provide care at home services. It is a very disparate mix of services and organisations. Care takes place in people’s homes (owned, rented or provided through supported accommodation), day care facilities and in care homes.

This chart shows just how complex the sector is for provision of adult social care. This covers all care services, including care homes, support services and care at home. You will notice that most provision is by private companies across all age groups.

Proportion of private, voluntary and other social care provision for adults

There is much national guidance and legislation that affects all services and providers. Social care is regulated by the statutory regulator, Social Care and Social Work Improvement Scotland (known as the Care Inspectorate).

When someone is entitled to social care support, assessments (financial and needs/outcomes), are carried out by local authorities, and if someone is entitled to financial support, it is the local authority that will fund the social care and support.

There are also a large number of unpaid carers looking after family members, neighbours and friends.

This blogpost does not cover services for children or young carers.

Some facts and figures:

In Scotland, at 31 December 2019:

  • There are 817 care homes for older people.
  • There are 1,473 Support Services (1044 care at home).
  • There are 56 Adult Placement Services.

These were some of the 12,600 or so services registered with the Care Inspectorate at 31 December 2019.

NHS ISD, now part of a new body, Public Health Scotland, publish a range of statistics including an annual care home census. In 2019, it  published an Insights into Social Care in Scotland (2017-18) (an experimental statistical publication:  these are official statistics which are published in order to involve users and stakeholders in their development and as a means to build in quality at an early stage. It is important that users understand that limitations may apply to the interpretation of this data )

How many people are in care homes and in Scotland?

Every year a care home census is carried out of all care homes (not just those for older people). The latest census data we have is from the 2018 ISD report. A census provides a ‘snapshot’ taken on a particular day across the country.

  • There were 1,142 adult care homes on 31 March 2017 with 40,926 registered care home places.
  • There were 35,989 adults in care homes. 91% of these were older people and two thirds were female. Men make up a higher proportion of people in care homes aged under 65.
  • Of every 1000 adults in Scotland, 7.7 are looked after in a care home.

How many people receive care at home in Scotland?

According to the Insights into Social Care in Scotland publication,67,985 people received home care during January to March 2018, with a weekly average of approximately 10 hours per person. (Not all areas submitted data)

How many people under the age of 65 live in care homes?

Numbers in care homes have fallen over the past decade as more people have accessed self-directed support and live with support in the community

From the Care Home census data, 2018 report:

  • In 2017 the number of residents in a care home for adults with a physical disability was 568.
  • The number of residents in a care home for adults with mental health problems was 949.
  • The number of residents in a care home for adults with learning disabilities was 1,542.
  • The number of ‘other’ vulnerable residents in care homes for adults was 239 in 2017.

How many people have died in care homes with COVID-19?

There has been much discussion and some confusion about how many deaths have occurred in care homes across the UK since the beginning of the outbreak, and about the reliability of the numbers published.

Deaths in hospital of people with COVID-19 are easier to record and collate because patients are being tested for COVID-19, if it is suspected when they are admitted. The data is collated centrally by Health Protection Scotland and reported directly by the Scottish Government. The daily figures published by the Scottish Government are those who have tested positive for COVID-19 and died within 28 days. (Testing can be carried out on a person once they have died but it is not clear to what, if any, extent this is being done).

Deaths in care homes, by contrast, have been subject to the normal death registration processes see SPICe blog ‘How are Deaths Counted?’. These processes have been streamlined. Since 2 April deaths in the community have been reported more quickly.

Since 12 April, National Records for Scotland (NRS) is now able to tell us whether someone, where COVID-19 is mentioned on the death certificate, died in hospital, a care home or in the community (at home, or at least not in an institution). On 6 May NRS reported that

The proportion of COVID-19 deaths which took place in care homes has risen each week and represented 59% of all COVID-19 deaths in week 18. Although the proportion of care home deaths has increased from the previous week, the number of deaths in care homes has fallen – from 339 to 310.

To provide some context, NRS stated:

 The total number of deaths registered in Scotland from 27th April to 3rd May was 1,673 – 594 (55%) more than the average number of deaths registered in the same week over the last five years, 1,079. This is a decrease of 163 from the number registered in week 17. Of these 594 excess deaths, 83% were deaths where COVID-19 was the underlying cause of death.

Have there been more deaths than expected at this time of year?

In the week from 13-19 April, NRS tell us that there have been 844 excess deaths (deaths over the 5 year average of 1067 for the corresponding week) and that 75% of these were due to mention of COVID-19. In addition, 10% have been from Alzheimer’s/dementia.

They also tell us that 74% of those where COVID-19 is implicated are over the age of 75. Coronavirus (COVID-19) could be said to be having a greater direct and indirect impact on older people. We are not told the age of those excess deaths from non-COVID-19 causes, but we do know that dementia is primarily a condition of old age.

How many people have died in the community with COVID-19?

As of 19 April, 168 (up from 128 the previous week) people whose deaths were registered and COVID-19 featured on the death certificate, died at home or in a community setting, such as supported accommodation. These would include people who have been advised to self-isolate at home with mild or moderate symptoms. We do not know why these people were not admitted to hospital, and in some cases, the certifying doctor may have to had to suppose that the most likely cause of death was COVID-19, because tests have not been carried out in the community.

Why hasn’t there been testing in care homes or the community?

Guidance published on the 1 May has introduced testing for those entering care homes as residents (see below).

And on 1 May, the First Minister said:

Currently around 40% of our care homes have cases of coronavirus within them.  We already test care home residents with symptoms, those being admitted to care homes and symptomatic care home staff.  I can confirm that we will now expand that approach.

We now intend to undertake enhanced outbreak investigation in all care homes where there are any cases of COVID – this will involve testing, subject to individuals’ consent, all residents and staff, whether or not they have symptoms.

In addition, where a care home with an outbreak is part of a group or chain and staff might still be moving between homes, we will also carry out urgent testing in any linked homes.

We will also begin sampling testing in care homes where there are no cases. By definition this will also include testing residents and staff who are not symptomatic.

https://www.gov.scot/publications/coronavirus-covid-19-update-first-ministers-speech-1-2020/

Prior to this, despite planning for community testing, it wasn’t widespread anywhere in the UK. Contact tracing was underway in England from 12 March, but it ceased across the UK by 2 April. It is not clear what contact tracing was carried out in Scotland.

Early in March, some community testing was established, such as in NHS Lanarkshire and NHS Greater Glasgow and Clyde. Nurses and healthcare clinical support workers were visiting people in their homes to collect samples for testing, rather than coming into contact with others in the likes of GP practices or hospitals. People were referred via NHS 24, and told to phone 111. People were not able to turn up to the clinics without an appointment. This means that the system was only fully effective if there was enough call centre capacity and clinical advice on hand at NHS 24. More information on testing can be found in the FAQ Health Blog.

The First Minister said on 15 April that 433 care homes had recorded at least one case of COVID-19 since the start of the outbreak. The Scottish Government are also planning to target test key workers. Cases are reported to the care inspectorate and cumulative cases and care homes affected are reported daily.

The Royal College of GPs expressed concern over the lack of testing in care homes, saying that they without knowing the status of people it was impacting on treatment, as well as advice they could give to the care home staff.

The Scottish Government have said from the outset that testing of frontline health and care staff is a priority.

On 25 April, the Scottish government issued guidance for the testing of key workers, in a prioritisation matrix. This puts all NHS and social care staff in the top priority with the following detail.

“All NHS staff and independent contractors working for the NHS, including community pharmacy and emergency dental care.

All social care and social work staff working with vulnerable people and the social care system, including care homes, care at home and children’s services (including residential and secure care for children), and social care personal assistants (note key workers in these groups who are not employed through an organisation will access testing, where this can support a return to work, through the UK Government schemes)”

through the UK Government schemes)”

In updated guidance issued on 1 May  following earlier guidance and a statement by the Health Secretary on 21 April

“the following groups should be tested:

· All COVID-19 patients in hospital who are to be admitted to a care home

· All other admissions to care homes”

How do care services access clinical help with suspected COVID-19 cases?

Care home staff access out of hours and GP care in the same way as other people – by contacting the surgery or calling 111. During the first week of ‘lockdown’, advice changed, telling people to contact NHS 24 rather than their GP if they had COVID-19 symptoms, to give GPs more time to continue with non-coronavirus related work.

Has NHS 24/111 coped with the increased demand to its call centres for suspected COVID-19 cases?

Around the time that lockdown was announced, call volumes at NHS 24 were extremely high, with nearly 12,000 being taken on 23 March and each of the preceding two days. This doesn’t of course indicate the number of people unable to get through. Answered call volumes are fluctuating between about 3000 and 9000 per day to 111 with far fewer to the non-urgent helpline number, by a factor of about 10. The chart below shows that there is a sharp spike in calls at weekends. This could be explained by the normal out of hours, non-COVID-19 activity, when GP surgeries are closed.

While little seems to have been reported on the heavy demands made on the 111 service, which is normally an out of hours service, this NHS 24 board paper for April details the unprecedented demand. This has been exacerbated by staff absence (nurse practitioners and call handlers), which was around 30% over ten days.

The paper details the steps taken to meet the increased demand, including the redeployment and recruitment of additional staff, with compressed training regimes.

“It is estimated, based on recent and projected demand, that to support the out-of-hours period we require an additional 140 Call Operators to take our total to 200 during the in-hours period. Subsequently this will require 40 Nurse Practitioners and 14 Senior Charge Nurses providing an overall maximum capacity to manage approximately 3600 calls.”

They have also commissioned an external provider, Ascensos, to run a special helpline from 8am – 10pm able to handle 5000 calls a day and provide a web chat facility. It is not clear how or if callers would be transferred between this and the main NHS 24 call centre, and whether they receive any clinical support or guidance.

What guidance has been given to care home and home care staff to protect themselves and the people they care for?

Guidance for care homes:

The most recent guidance, specifically for care homes was published on 1 May by Health Protection Scotland.

Immediate actions if it is suspected that a resident is infected:

“· Return the individual to a single room or to an area at least 2m away from any other residents (staff within 2m should be wearing PPE).

· Seek prompt medical attention if their illness is worsening. If it is not an emergency, contact NHS 24 (111).

· If it is an emergency and you need to call an ambulance, dial 999 and inform the call handler or operator that the unwell person may have coronavirus (COVID-19).

· Follow testing advice.

· Follow isolation advice.

· Provide ‘warn and inform’ letters to individuals, visitors and staff if there is a suspected case of COVID-19 in the home.”

It says that people with suspected COVID-19 can be accommodated in a room together as can those who have tested positive. However, it also states that a suspected case and a confirmed case should not be in the same room (‘cohorting’) and if a resident is in the ‘shielding category’, they must be in their own room.

If a care home has more than two suspected cases, then they should contact their local health board Health Protection Team, and phone numbers are available in the guidance.

Is there any other guidance on looking after people in care homes with COVID-19?

Palliative care guidelines have been issued for people who have not been transferred to hospital with severe COVID-19 symptoms. This recognises that some staff are having to look after people in circumstances that are not ‘normal’. It has become clear that some people can decline very rapidly:

“The focus of this guideline is to reduce the suffering for those dying from COVID-19 lung disease.

A proportion of patients dying of COVID-19 lung disease could have severe symptoms with rapid decline. In this situation it is important to deliver effective medications, at effective doses, from the outset. Early management of symptoms will be the most effective way to reduce suffering.”

What guidance is there for home care staff?

Health Protection Scotland issued guidance for all health and care sectors, which was updated on 17 April. ‘Information and Guidance for Social or Community Care and Residential Settings Version 1.7’ is no longer available online and there is now no specific  HPS guidance for those providing social care in non-residential settings such as home care staff and personal assistants other than the general guidance on non-healthcare settings.

However, the Scottish Government have issued guidance for these staff: Coronavirus (COVID-19): clinical guidance for the management of clients accessing care at home, housing support and sheltered housing, published on 26 March.

Is there any guidance for unpaid carers?

In this same compendium of Scottish Government advice is specific guidance of unpaid carers, updated on 20 April including how to access PPE.

The Coalition of Care and Support Providers, CCPS, the representative body for voluntary sector care provision, has collated a range of useful resources  for staff and organisations.

The BBC have reported that support at home has been under severe pressure, with people losing the support they had been getting.

What Protective Personal Equipment should be made available for social care staff?

The whole of the UK and the medical Royal Colleges have agreed a PPE protocol for all settings. This outlines what equipment should be worn in different settings and circumstances. This table is included in the guidance for care homes and community settings.

The route for social care staff accessing PPE equipment is not quite the same as for NHS staff. But in both cases, a person’s employer is responsible for supplying it.

However, the updated guidance for care homes states the following:

“Access to personal protective equipment (PPE) All services who are registered with the Care Inspectorate that are providing health and care support and have an urgent need for PPE after having fully explored local supply routes/discussions with NHS Board colleagues, can contact a triage centre run by NHS National Services for Scotland (NHS NSS).

Please note that in the first instance, this helpline is to be used only in cases where there is an urgent supply shortage after “business as usual” routes have been exhausted and a suspected or confirmed case of COVID-19 has been identified.

The following contact details will direct providers to the NHS NSS triage centre for social care PPE: Email: support@socialcare-nhs.info Phone: 0300 303 3020. The helpline will be open (8am – 8pm) 7 days a week.”

What happens when an older person is ready to leave hospital during the pandemic?

In updated guidance issued on 1 May, all people entering care homes should be tested for the virus that causes COVID-19. All people who have been in hospital with COVID-19 should have two negative tests at least 48 hours before discharge, and at least 24 hours apart. If they have not had COVID-19 symptoms, they should have one test, 48 hours prior to discharge. They can be moved before the result is known. All residents coming into a care home from the community should be isolated for 14 days and be tested prior to or on admission.

“The First Minister announced changes to testing of residents and staff in care homes on 1 May 2020.


“We now intend to undertake enhanced outbreak investigation in all care homes where there are any cases of COVID – this will involve testing, subject to individuals’ consent, all residents and staff, whether or not they have symptoms.
In addition, where a care home with an outbreak is part of a group or chain and staff might still be moving between homes, we will also carry out urgent testing in any linked homes.

We will also begin sampling testing in care homes where there are no cases. By definition this will also include testing residents and staff who are not symptomatic.
This is a significant expansion and we do not underestimate the logistical and workforce requirements.


Now we have the increasing testing capacity, we will make it happen as swiftly as
practicable.”

 

Prior to this guidance for the care of people being discharged from hospitals to care settings, published on 11 April stated that universal testing of people being discharged was not recommended:

“If testing for viral clearance is available, it should focus on:

 the risk to the discharge location, for example:

  • patients discharged to a residential care setting if strict isolation is expected to be challenging; or
  • those being discharged to a household containing someone who is being shielded.
  • the severely immunocompromised or those following shielding measures (viral shedding may be prolonged); and
  • any testing which optimises patient flow through the hospital, such as patients who are unable to otherwise be discharged.”

What have been the trends with delayed discharges?

Delayed discharges are the result of people remaining in hospital when clinicians are satisfied that they are well enough to be discharged. The Scottish Government’s daily trends data  provides information on delayed discharges. On 4 March there were 1612 patients in hospital deemed fit for discharge. By 24 April this had fallen quickly to 582.

This may have been, and remain, significant in relation to infection as potentially vulnerable people are moving between high-risk environments when most people are staying at home, except in a small number of circumstances.

The chart below shows the sharp decline in delayed discharges since March 2020, following a relatively stable level for the previous year.

Delayed discharges since April 2019

The emergency legislation, Section 16 of the Coronavirus Act 2020 allows for people to be moved out of hospitals without the usual consultation with family or welfare guardians, or with the person themselves. People can be discharged to their own homes or care homes.

How are safety and compliance being monitored in social care services during the outbreak and what is the role of the Care Inspectorate?

The Care Inspectorate is the public body that has a statutory duty to register and regulate all care services. It seeks to provide assurance and protection for people using registered services. It inspects services, and can ultimately cancel the registration of a service if it is not abiding by the conditions of registration or by the care standards. Its website states that:

“The Health and Social Care Standards have been developed using human rights and wellbeing principles. This means empowering people to know and claim their rights and increasing the ability and accountability of individuals and institutions who are responsible for respecting, protecting and fulfilling rights.”

The Care Inspectorate has halted all inspections, and is seeking to provide assurance and support remotely. The Scottish Government has provided the following information:

“It is a fast moving picture but at the time of writing the Care Inspectorate (CI) consider it is no longer tenable to adhere to ‘business as usual’ principles so are not routinely visiting care homes (because of social distancing guidance, and not putting undue pressure on services). The overriding principle is to postpone non-essential scrutiny and assurance activity.  We understand this is in line with the approach being taken by other UK regulators.  Furthermore, the CI is introducing remote monitoring of and support to care homes using technology such as “Near Me” video linking with care homes rather than physical visits. 

Whilst the CI has repurposed the organisation and is not currently doing inspections during the emergency period it is becoming more intelligence led and are providing support to care services working in partnership with others.

Activities

It would not be accurate to say there is no longer any action or activity on concerns or complaints raised and the following information may provide more insight.  

  • CI is closely monitoring services and has been making regular contact with care homes, often daily, their parent companies, Health Protection Scotland, local Public Health teams, Health and Care Partnerships, Local Authorities and others in order to monitor, direct and guide services
  • All care homes are asked about staffing levels, management arrangements, PPE, practice in response to Covid-19 and the management of the accommodation areas within the service, as well as more broadly offering support to the service
  • CI has put in place a daily notifications process for suspected cases and deaths in care services and has established a new system of notifications for services to indicate if they were experiencing staffing difficulties
  • Data is examined on a daily basis alongside the intelligence following direct contact with services and partner agencies
  • CI is working jointly with the SSSC / NES recruitment hub to successfully route staff to services experiencing staffing difficulties, as well as assisting services source PPE

Deaths and cases in care homes are being reported to the CI

During the outbreak the Care Inspectorate has been maintaining regular contact with all care home and care at home services to provide advice, guidance and support to them directly or galvanise support for services from others.  This has included confirming, amongst other things, adherence to national guidance around infection, prevention and control, staffing levels and availability of PPE. This is often done in collaboration with public health teams and Health and Social care Partnerships (HSCPs).”

Is it true that people in care homes are being encouraged to complete ‘Do Not Resuscitate’ (DNR) forms?

There has been some alarm in media reports about ‘difficult decisions’ clinicians might have to make about who to treat if equipment and clinical time have to be ‘rationed’ because of increased demand and staff absence during the outbreak.

It is the case that staff are being encouraged to ensure that conversations are had with people and end of life wishes are recorded and up to date. This is called ‘anticipatory care planning’ (ACP). Do Not Resuscitate (DNR), or DNACPR (Do Not Attempt Cardiopulmonary Resuscitation) decisions are part of the anticipatory care planning process (see below). These are completed by health professionals – doctors or nurses, and not care home staff.

Key Information Summaries (KIS) are part of this process,and provide an easily readable summary of a person’s clinical information that can be passed between primary and secondary care.

Part 6 of the KIS guidance, that has been specifically issued in relation to the COVID-19 pandemic, states the following:

“6. Check information in the KIS special note is still correct check that next of kin and power of attorney information is up to date If appropriate ask ‘If you were to become very unwell with coronavirus or another illness, is there anything that you would like us to take into account whilst caring for you? (e.g. treatments that would or would not be acceptable to you / preferences for care) and go where this conversation takes you. Update special note with any additional information Include the wording “updated as per Covid19 protocol”

The Government has published guidance for clinicians, based on a range of legislation and existing guidance on end of life decision-making.

It reminds clinicians how they should make decisions with people, and not for them.

The ethical framework developed by the Committee on Ethical Aspects of Pandemic

Influenza was first published in 2007 and revised by the Department of Health and Social Care in 2017. This framework outlined the fundamental principles that all people should be treated with equal concern and respect:

•           Everyone matters

•           Everyone matters equally – but this does not mean that everyone is treated the same

•           The interests of each person are the concern of all of us, and of society

•           The harm that might be suffered by every person matters, and so minimising the harm that a pandemic might cause is a central concern

These principles continue to underpin the work of the UK Medical Ethics Advisory Group, but the more recent guidance reflects changes in society and thought since the Influenza pandemic guidance was published in 2007, and the guidance is under headings such as ‘respect’, ‘working together’, ‘minimising harm’ and ‘fairness’.

There is also clinical guidance for community nursing and allied health professional staff in relation to COVID-19, which does refer to DNR forms: ‘National Clinical Guidance for Nursing and AHP Community Health Staff during COVID-19 Pandemic’. A new template for ACPs is included, updated for COVID-19

Section 9 is on Anticipatory Care Planning, (ACP) and that staff should make sure that these are in place. A new template for ACPs has been produced by NHS Healthcare Improvement Scotland:

https://ihub.scot/improvement-programmes/living-well-in-communities/anticipatory-care-planning/.

The Royal College of GPs (RCGP) has collated the guidance for GPs from each of the four governments:

Included in this collection is one that refers to the KIS, the Key Information Summary, which is the document GPs are also being asked to check is up to date. They have also been told that they can share these KIS’s with other appropriate professionals without seeking explicit consent from individuals.

It is recommended as best practice that a DNACPR form is included in the KIS.

Anne Jepson

Senior Researcher, Health and Social Care