Case Studies

''OUR FAMILY CARE HOME IS NOW EMPTY... OUR RESIDENTS ARE ADVISED TO STAY PUT EVEN THOUGH IT'S SAFE TO COME BACK... WE ARE DEVASTATED'' Care Home Manager

''Our care home was evacuated under an emergency situation on 23/12/20. The home had managed through the whole Covid-19 pandemic without issue until 18/12/20 when results for 6 staff tested on 14/08/20 were received and were positive. These staff had been asymptomatic and working. We do not know if it was the new variant or not but the speed of transmission would suggest so. Immediate action was taken – all staff on duty were LFD tested (newly available as of that week), and cases were found. Residents were tested and three were already positive. All residents were isolated, and barrier nursing was instigated for all. Further staff testing positive was a concern and the following day (19/12/20) I contacted the home to voice concerns about how we manage the situation.

On Monday 21/12/20 I made the decision to retest all the negative residents and found more cases. They were already isolated and barrier nursed by this stage. I was not asked to do this by any agency including PHE but chose to do this as a responsible action. On Tuesday 22/12/20 I chose to LFD test all staff pre-shift – 3 staff who had tested PCR on 21/12/20 were positive, including the nurse, so I sent her home and I worked as the nurse 8-8. Again, the decision to LFD test pre-shift was mine and was done from a sense of responsibility, I received no guidance to do this.

I escalated to GCC and a series of increasingly desperate emails ensued. Finally, residents were moved to xxxxxxxxx on a temporary basis because so many of our staff were self-isolating. Only the kitchen staff (six people), four carers and two nurses were left still negative and three more tested positive at the next PCR on 29/12/20. Learning: I feel there is little we could have done differently at the time. I have been told today (07/01/20) that I did not take it seriously, did not manage it well and failed to escalate quickly. I am concerned at this comment, and find it alarming, coming from a partner. I escalated on 19/12/20, the day after we knew we had an issue, and before we hit a crisis. I chose to not only adhere to guidance but to go above and beyond the guidance, including LFD testing and the wearing of full hazmat suits, and there is much evidence that it was taken very seriously indeed.

IPC guidelines were well embedded within our practice – evidenced by nine months of no outbreak. We had a previous case of an agency worker who had worked in the home for two days, and on a separate occasion one of our carers testing positive, and no transmission occurred on either occasion which evidences effective IPC. The crucial difference was that it was 1 staff member at a time and the new variant had not surfaced at that time.

I have been told that had our IPC protocols been strong enough this would not have happened and that other homes have had outbreaks and have managed them successfully. I find this comment unsupported and alarming from a partner. Firstly, our protocols went above and beyond guidance. What changed things for us was twofold – the 14/12 tests were not collected by the courier despite a collection being booked. This meant that there was a delay in getting results. 6 staff is a huge amount in one cohort of testing. Secondly, what I think we may have been dealing with is the new variant, and if so, what we thought we knew about prevention of transmission is less adequate in these circumstances. The guidance in place at that time will slow down but not prevent transmission. Any care home would struggle to manage that scenario and I don’t think there should be blame on any party, but I do realise we need to plan for the new threat we all face (see below)

Future Mitigation and Learning:

Our IPC procedures remain broadly the same as before with the addition that we now have LFD testing pre-shift. These procedures were stringent and well embedded prior to this outbreak. Throughout the pandemic, we have maintained good supplies of PPE. Staffing levels are extremely good and under normal circumstances, we do not need to use any agency. What happened from 18-23/12/20 was wholly abnormal circumstances. Staff are not working elsewhere. Staff are well trained both in IPC and Covid specific knowledge, and all have been asked to complete and therefore refresh their knowledge whilst they are currently furloughed.

We will initially cohort residents into the new building where possible. This is purpose-built and lends itself much more easily to the management of outbreaks. Staff will be deployed to either upstairs or downstairs to mitigate risk in terms of further positive diagnoses. Whole-home testing will continue as it has from the outset. IPC is discussed at handover daily and has been since the outset of the pandemic. I believe this is important to ensure cohesiveness, address any misunderstandings and ensure uniformity of practice.

I communicate with residents and relatives as a matter of course. Before the evacuation, I communicated with relatives at least weekly and we had a regular ‘Friday night update’ going. Transparency has been evidenced from the outset and will continue. Positive residents were told/their relatives informed as soon as we knew and all relatives were informed of the situation right from the initial start of the outbreak. Everyone has been fully aware of what the situation has been at all stages until they left us. This would continue again, as before.

Staff are organizing vaccination when time-lapse allows after the last positive result. By end of February 2021, ALL staff should be vaccinated.

I understand residents are being vaccinated today (07/01/21 and if so, residents should have a level of immunity to safely transfer back, and mitigate future risk. I have written to the Director of Public Health GCC, and have today received a reply. I would like a public health overview and sign off. I do not at this time, with the knowledge and guidance currently available think we can do any more. I feel that with respect, the bulk of work needs doing within the CCG and GCC to look at strategies should this situation arise elsewhere – with the combination of the new variant and the advent of LFD testing, there is a very real possibility it will.

The outcome of this work needs to be communicated with providers. The situation with us was uncoordinated in that it very quickly became apparent that there was no planned response in place to cover a major outbreak. I do not believe there is necessarily blame in this, but I do think that what happened to us, happened with very robust IPC protocols in place, and could therefore happen to anyone. There needs to be a clear framework to clarify IF this situation arises again, the chain of command and steps. Specifics of a move back:Residents should be RAG rated from a medical point of view for suitability and ability to be transferred. I did a piece of work yesterday, emailed to xxxxxx and shared this is without up to date knowledge of current health statuses. The GP should sign off on this.

Based on suitability, GCC needs to establish capacity, and again, I have given xxxxxx an overview of those likely to have the capacity and those likely not to have. Views need to be ascertained. From what I know, people appear to want as speedy a return home as possible. XXXXXXXX was an emergency placement and was not designed or intended to be a permanent residence. Consent to go there was gained on that basis. I/CCG nurse needs to establish any specific needs or changes since last at our home particularly any Covid/Post Covid related needs. This needs to be communicated with us.

Vaccination/LFD status/Antibody status should form part of the assessment.

Residents should be moved back based on RAG status, and will not happen in one cohort, but likely in a phased way. There should be an agreed Post Covid plan including protocols around oxygen and escalation (temporary until signed off as recovered/vaccinated)Transport: National Lockdown has considerations but does not make a move impossible. Vaccination status will be taken into account.

''Now we are all better and desperately want the residents back, obstacles are being put in our way and in fact, the comms from GCC to families is biased to almost persuading them to keep their loved ones at the home they were supposed to be temporary.'' Care, Home manager,

CARE CAMPAIGN FOR THE VULNERABLE IS SUPPORTING THIS CARE HOME MANAGER. IF YOU ARE INTERESTED IN THIS CASE STUDY PLEASE CONTACT ccftv.cares@gmail.com

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