Support for care homes in Tower Hamlets

This report sets out a summary of work the council has undertaken with partners (through the Integrated Care Partnership Tower Hamlets) to support local care homes during the coronavirus pandemic.

The council has worked closely as a partnership to ensure the best possible support is available for care homes at this challenging time.

• London context
• Tower Hamlets context
• Local care homes context
• Direct provider support - advice, information and guidance
• Clinical ‘wrap around’ support
• Personal Protective Equipment (PPE)
• Infection Prevention and Control (IPC)
• Workforce and recruitment
• Staff wellbeing
• Testing
• Financial support
• Impact of coronavirus
• Next steps
• Appendix
• Care Home Action Plan Update

London context

Coronavirus O has presented an unprecedented challenge to adult social care. The challenge has been significant in London due to the early and rapid spread of the virus, local patterns of deprivation, high levels of air pollution and the high proportion of ethnic minority populations in most London boroughs.

Across the capital, London local authorities responded to the challenge and our responsibilities under the Civil Contingencies Act by working together as London Association of Directors of Adult Social Services (ADASS) and Chief Executives, alongside NHS partners to identify issues, galvanise responses and lead several pan-London initiatives. We brought our coordinated response together through the Strategic Co-ordination Group (SCG) and joint governance with NHS London.

Using data and evidence we developed a comprehensive understanding of the London adult social care markets (home care and care homes) during the spread of coronavirus. Our commissioners used this as a key part of their daily interaction to support providers. It has underpinned and strengthened relationships with providers locally and provided information on care homes across borough boundaries, which has streamlined the work and reduced the burden on providers. Since mid-March this has supported local operational responses: prioritising active delivery of Personal Protective Equipment (PPE), ensuring appropriate staffing levels and providing public health infection control advice and support.

Being alert to emerging issues in system which led to care home challenges and our early response (we started reporting care home deaths and coronavirus cases from 23 March 2020) allowed action to be taken to respond in London and provided early warning nationally via the SCG of issues that would develop across the country.

Tower Hamlets context

Tower Hamlets has a population of 324,745. It is a relatively young borough – the number of older adults aged over 65 years is 20,859. While the borough has high levels of deprivation and high levels of health inequality; It is also one of the most vibrant and diverse communities in the UK. More than two-thirds of our population belong to a minority ethnic group and we are the sixteenth most ethnically diverse local authority in England with almost 140 languages spoken in our schools. People value the rich cultural offer that comes with this mix, and the new opportunities to celebrate this diversity that we have worked hard to create.

Over the past three decades our population has more than doubled and currently sits at over 300,000, with a projected population of over 380,000 by 2030.

Tower Hamlets has significant levels of serious mental illness together with high numbers of people living with common mental health disorders and high levels of socio-economic deprivation, in particular child poverty, which leads to significant risks to mental health. GP registers show that the adult population in Tower Hamlets has higher levels of severe mental illness (1.34%, 4527 patients) than London or England along with significant levels of common mental health issues.

Tower Hamlets has an estimated 4,848 people aged 18 and over who have learning disability.

We aim to support people to maintain their independence at home and in the community. Admissions to residential and nursing care are generally low and the numbers of those supported at home are high. There is very limited residential and nursing home provision within the borough (308 units for older people and 44 for people who have a learning disability or mental ill health). As of 30 April, 328 people aged over 65 were placed by the borough in residential and nursing care homes, of which 192 (59%) were placed out of borough. There were 136 people placed in borough 33 were placed in nursing care and 103 in residential care.

The Tower Hamlets Together (THT) Partnership (borough based integrated care partnership) is well established in the borough and brings together all the key partners across the system, including the council, the Clinical Commissioning Group (WEL – Waltham Forest and East London); Barts NHS Trust; East London Foundation Trust; GP Care Group; and the Council for Voluntary Service. The strength of the partnership has allowed us to respond quickly and appropriately to deal with the impact of coronavirus.

Local care homes context

There are 10 care homes registered with the Care Quality Commission (CQC), offering places for up to 352 people in Tower Hamlets. This includes:

• 90 units of nursing care – one home
• 75 units of residential / nursing care – one home
• 143 units of residential care – three homes
• 20 units of mental health accommodation – two homes
• 10 units of mental health and learning disability accommodation – one home
• 7 units of learning disability accommodation – one home
• 7 units of learning disability respite accommodation – one home

The borough directly commissions the five nursing and residential homes and the two learning disability specific schemes; the other three homes are accessed by the borough on a spot purchase basis. Of the five older persons’ care homes, one is rated as outstanding, two are rated as good and two require improvement.

The borough is working closely with the CQC and providers to achieve the requirements to attain a minimum of good in all areas and in the last six months has seen improvements in quality reported by the CQC. The homes are monitored through quarterly reporting and by way of an annual multi-disciplinary team visit. The team is composed of a broad range of partners including representatives from Tower Hamlets CCG, safeguarding team, older adults mental health team, community health services, community pharmacists and commissioning officer -, all of whom contribute to the final report.

The borough delivers and facilitates access to a broad range of training offers and promotes the adoption of and access to a range of standards including Quality Matters. Quality Matters aims to achieve a shared understanding of what high-quality care is, more effective and aligned support for quality in adult social care, and improved quality that can be measured. Two care homes have achieved the requirements of Gold Standards Framework for End of Life Care. The programme is designed to improve the organisation and quality of care that is offered to patients and their carers in the last six to 12 months of life.

Going forward we want to ensure that:

• there is sufficient supply of nursing care and residential dementia care beds in the borough so that every older person who needs a nursing / residential placement is able to access a suitable local option if that is their / their family’s choice.
• capacity is increased by 25% or 75 units in accordance with population projections in POPPI indicate that we will need to increase bed capacity by 2025.
• contracting arrangements are reviewed with providers to consider block arrangements to both the existing and new provision to ensure that the borough has access to additional space, to reduce competition with other local authorities and self-funders who are seeking access to in borough homes.
• all of this bed capacity is delivered in care homes that have at least a Good rating from the CQC.
• through a combination of capacity, flexibility of service model inclusive of extra care; and responsiveness of assessment and admission processes (on a 24/7 basis) that no discharge of an older person from hospital will be delayed by non-availability of provision.
• admissions to hospital from care homes reduce.

All of the five mental health and learning disability services are rated as Good. We work closely with providers to ensure services are personalised, reflect the needs and wishes of individuals and promote and enable people to be as independent as possible and are actively working to expand local accommodation opportunities.

Direct provider support - advice, information and guidance

 Tower Hamlets has an integrated commissioning team across the local authority and the CCG. All communication and planning with care homes is therefore joined up and can be reported back into both organisations. An integrated support offer across community and primary health and social care has been provided to care homes and to extra care during the coronavirus pandemic. Commissioners have worked very closely with public health colleagues both at a local and national level to further supplement and develop the offer to providers, at the onset of an outbreak, through to its conclusion.

All care homes across older adults, mental health and learning disability categories have been contacted by a dedicated member of the integrated commissioning team each working day with effect from 24 March to confirm their current operating status, gain an update in respect of infections, staffing and PPE for example, to establish whether there is a need to lever in any further support. This information is monitored daily by senior managers and urgent issues are identified and acted upon. In addition to this, the integrated commissioning team introduced a duty rota so that urgent issues can also be dealt with out of hours.

The integrated commissioning team circulate all offers of support and information, advice and guidance to the care homes from local, regional (including London) and government sources.

This is supplemented by a weekly partnership meeting / teleconference to support older people’s care providers specifically. This has expanded over time and now includes colleagues in the local authority, CCG, GP Care Group, Barts Health NHS Trust, East London Foundation NHS Trust and CQC. Over 30 people are invited to attend each week, and routinely all providers take part and there is generally a high level of attendance. The focus is on the offer that we can give to support the care homes, and to share experience and knowledge as it develops through the pandemic. Providers are also encouraged to remain on the call at the end, by way of peer support, and we have facilitated care homes managers to actively help each other, where there has been an outbreak in a home for example.

Our initial focus was on older adults services who were experiencing the greatest pressures. We have now expanded this to include mental health and learning disability care homes. The key focus being on supporting the homes to address the challenges of implementing social distancing in smaller group home settings for people with mental health and learning disabilities, and ensuring appropriate support is available to both staff and service users in understanding the guidance and how to keep everyone as safe as possible. This is still in the initial stages and we plan to expand this over the weeks ahead.

The care homes regularly complete the daily ADASS older persons bed-based care returns which feed into the market insight tool as well as the Department of Health and Social Care (DHSC) capacity tracker. All mental health and learning disability schemes are completing the capacity tracker and we have been working closely with ADASS to ensure the effective rollout of their daily return to these homes.

These tools enable providers and commissioners to better understand the quality of care provided across the borough and beyond and better monitor trends. For example, recent analysis of the coronavirus PPE returns by the London School of Economics identified significantly different trends across London in respect of nursing and residential care homes supply and usage of PPE.

Clinical ‘wrap around’ support

In respect of clinical support, all older peoples’ care homes in the borough now have access to an enhanced GP service. The offer, was initially for the two nursing homes, and had been extended to include the three residential care homes during coronavirus. Key facets of this include delivery of a weekly ‘check in’, to review patients identified as a clinical priority for assessment and care, in-hours urgent care where GP input is available within two hours of a request being made and the ongoing review and updating of personalised care plans. Alongside this, we will be reinstating multi-disciplinary team meetings in early June, in virtual form, for each of the homes, with input from GPs, community health services staff, community geriatricians, mental health specialists and medicines management. This will provide additional and ongoing clinical input.

Each older persons care home has a named clinical lead and a designated community health services clinical lead attached to each care home, which complements the primary care offer detailed above. To date this has not been rolled out to mental health and learning disability homes despite enhanced support being provided from learning disability and mental health community teams. We are currently prioritising this to ensure there is an enhanced local offer to these services with a designated clinical lead in all circumstances.

Clinical staff from our acute provider and from our community health services also join the weekly provider forum.

In addition to this, we have developed a standard operating procedure for care homes in Tower Hamlets advising them of the actions to take at varying points during an outbreak, which includes links to a broad range of information, contacts and agencies. This has been developed in conjunction with our public health team.

A wider handbook has also been developed between the local authority and the WEL CCG, giving an overview of the services available across Tower Hamlets, Newham and Waltham Forest.

Our local community health services have delivered 15 virtual training sessions in residential care homes on identifying and managing pressure ulcers and continence care. As a direct result care home staff rather than district nurses, can begin to undertake these tasks themselves, and reduce foot fall and the risk of infection. Equally, we are responding to training needs as they are requested – the latest request being the use of syringe drivers in the nursing homes.

Personal Protective Equipment (PPE)

 At the onset of the pandemic providers reported a range of difficulties in trying to access PPE. When able to make orders through their suppliers, the delivery timescales were not honoured, on occasion leaving providers with very low levels of equipment, some still not having access to the London Resilience Forum delivery. In order to bring some stability to the sector and allay the fears of staff, residents and family members, the borough developed its own mutual aid PPE offer.

The borough set up a dedicated team of staff with effect from 27 March to ensure that sufficient supplies of PPE are available to those who need it during the pandemic. The council recognises the challenges that smaller providers and indeed some larger organisations face in obtaining appropriate levels of PPE and introduced a mutual aid request scheme for PPE in early April. The scheme aims to support providers where they have been unable to obtain PPE through usual supply chains and where stock levels are such that care, and support services will be affected, for example they have less than three days’ supply of any item of PPE. The use of the NHS emergency supply scheme forms a backup to the boroughs own arrangements, should this be needed.

The service has a dedicated application form, telephone number and email address. It is primarily available during the working week; however, emergency supplies are available, through the coronavirus support system, an emergency supply being accessible from the town hall, which is open 24 hours a day seven days a week. To date the following items have been provided to the ten care homes:

• 4200 gloves
• 2590 fluid repellent masks
• 330 goggles including frames and lenses
• 100 face shields
• 4.5 litres of hand sanitiser
• 400 aprons

Infection Prevention and Control (IPC)

The care homes in the borough have a history of working very closely with the infection control nurses based in the Royal London Hospital, Barts Health NHS Trust. They are key members of the borough’s residential and nursing care forum and are invited to attend the weekly teleconference.

All providers have confirmed that staff are up to date with IPC training and to supplement this, we have circulated a wide range of information to them, including guidance, access to webinars and online courses in respect of PPE and IPC.

At a WEL CCG level two IPC nurses have been specifically recruited to support care homes and the borough support their work and has facilitated links with providers. WEL CCG are delivering a series of training sessions in the week ending 29 May to all care homes via a webinar in addition to the Public Health England training already provided. WEL CCG training is focused on:

• PPE
• testing
• principles of IPC

The borough is also exploring options to undertake a review of the design and layout of each care home, as it recognises that the environment is critical to the management of IPC. For example, in respect of residential care homes, it appears that those that are able to cordon off areas in a safe way are better able to manage the needs of those people who purposefully walk and may have behaviours that challenge, such as those with dementia for example. This suggestion has been welcomed by providers and the borough is seeking to develop a small group to undertake this work inclusive of public health, environmental health, London Fire Brigade, provider and commissioning representatives. The brief will be agreed over the coming weeks and it is anticipated that the work will commence mid to late June. By having a better understanding of the requirements necessary to manage footfall it is anticipated that this work will also link to better planning for future pandemics, feeding into scheme risk assessments and business continuity planning.

Workforce and recruitment

The borough has undertaken a recruitment campaign for care home and domiciliary care staff and a dedicated phone line and inbox has been created to triage enquiries and refer expressions of interest onto local homecare agencies and bed-based settings. This service is aligned to the national recruitment and volunteer scheme and Proud to Care. To date, the borough has received some 200 enquiries and made over 60 onwards referrals to providers.

The borough has also developed a community hub for vulnerable residents to phone up who may require assistance, in the form of shopping and being signposted to support services for example. The care homes have access to this, and in one care home, befrienders now telephone residents who have no next of kin on a weekly basis to provide stimulation and reduce isolation.

Our care home providers have taken steps to minimise the transfer of staff between agencies. Many have their own banks of staff, and those that share an agency ensure that they use a different ‘pool’ of staff from within that agency where at all possible. For example, one nursing home has consistently used one agency nurse as a member of staff to ensure continuity of provision and minimise the spread of infection. Issues occur when staff do not turn up for their shift or give minimal notice on occasion - this has resulted in the use of agency staff. While one providers contract allows staff to work for two or more other providers, we are exploring options with the providers to see how the funding could you be used to better manage the process.

Staff wellbeing

We acknowledge that coronavirus has the potential to impact on staff wellbeing. To support those care homes run by smaller private companies who do not have access to employee assistance programmes we have arranged access to the council’s programme as an alternative. In addition, East London Foundation NHS Trust have arranged for care homes staff to be fast tracked in line with NHS staff to access their psychological therapy services. In the longer term we are reviewing options for group support as things begin to settle.

Testing

Initially, care home staff self-isolating at home were accessing testing through NEL CCG and were offered either home testing kits, or the option to use a drive-in testing facility in Greenwich. However, take up was found to be minimal, as there were issues accessing home testing kits due to limited supplies and equally, most of our care homes staff do not own a car, thus limiting their ability to use the drive-in facilities.

Care homes have been encouraged to access the portal and to date eight out of the ten care homes have registered. The majority have received testing kits, although one has been waiting some time. In addition to the national offer, the borough has introduced a local testing arrangement, in partnership with the GP Care Group and Barts Health NHS Trust. This involves a small team of advanced nurse practitioners (through the GP Care Group) visiting all of the older people’s care homes on a fortnightly basis to undertake the required tests, with results processed at the Royal London Hospital, Barts Health NHS Trust, where capacity has been freed up to support with this. We anticipate that the local process, from the beginning request, through to the confirmation of results, will take no more than two to four days. We will be looking to extend this local scheme into our learning disability and mental health care homes shortly.

Testing started the week commencing 18 May and by 29 May it is anticipated that that all staff and residents will have been offered a test. Data collated to date for three care homes is reported in the table below. This shows that while the take up by residents is high, the take up by staff is significantly lower. Anecdotal information suggests that staff who have been tested recently have declined a further test, and in particular those that have tested negative are not keen to repeat the test. This will be explored further on completion of the first set of tests across the care homes and options reviewed to incentivise take up.

Testing is undertaken for all of our care homes residents that go into the Royal London Hospital, Barts Health, NHS Trust. Where a service user tests positive for coronavirus, we have procured additional beds in the community, in partnership with WEL CCG, such that they can be discharged into these settings, until they have fully recovered and can return to their home.

Financial support

As part of our daily contact with providers we ask them to confirm their cash flow and financial position and ensure that payments are made in a regular and timely fashion. In addition to this, the council understands that the care homes may be experiencing a number of cost pressures as a result of coronavirus, including higher staff sickness absence rates, higher administration and higher PPE costs. As such, in line with recommendations from the Local Government Association (LGA) and ADASS, the council is providing them with a temporary 10% uplift, with effect from 1 April 2020. Providers have received the 10% uplift payments for April and May 2020, and we will issue additional payments over coming months, as required.

Going forward, we will continue to explore additional measures to ensure the viability of our local care homes. We are currently considering alternative contractual arrangements particularly when we are asking care homes to hold back from taking any new patients who test positive for coronavirus, admissions or discharges from hospital, in order to protect the communities that reside within them. We are also proactively exploring options to increase the supply of nursing beds within the existing homes, and in line with our market position statement are working with registered social landlords to increase supply of extra care provision which currently stands at 214 units in borough.

Impact of coronavirus

The borough has experienced infection outbreaks in the four of the five older adults residential and nursing care homes in borough. The outbreaks have been significantly more widespread in the nursing accommodation and beds, although this is not always reflective in the number of deaths.

As of 27 May the care homes have reported 37 deaths, 36 of which are confirmed to have been related to coronavirus and one of which we are awaiting the outcome, albeit suspected coronavirus related and included in the data. Of the total, 28 of the residents died in their care home and 9 in hospital. Seven residents are currently in hospital of whom four have tested positive.

Whilst  the number of deaths are higher in nursing care homes, it should be noted that they have a higher percentage of bed spaces than that of residential care. It should also be noted that the residents tend to be older and frailer in the nursing homes with several residents receiving end of life care.

Also, of reference is the fact that only 1% of residents in extra care, have died from coronavirus. The key difference likely being the self-contained nature of the accommodation which enables residents to more easily isolate.

As at 18 May there are currently 53 staff off work predominantly self-isolating with coronavirus related symptoms. Three staff have been hospitalised due to coronavirus during the pandemic, all of whom have recovered sufficiently to return home. Over the course of the pandemic to date, our providers have been operating with around 70% of staffing levels.

To date our five Learning Disability and Mental Health Care Homes have experienced limited cases of infection. There has been one death in one of our mental health care homes (which took place in the home), and one further confirmed case in the same home who has since recovered.

We have had no reported infection outbreaks in the three learning disability homes.

Next steps

During the coronavirus pandemic, our response prioritised our older people’s care homes. We have worked closely with all our providers and across the partnership, and this has included our mental health and learning disability settings, however our immediate pressures have been in our older people’s care homes. Many of our actions going forward are to ensure sustainability of these and extend the actions we have taken in these settings to our mental health and learning disability settings.

Our Care Homes Action Plan covers a range of actions completed and underway. Over the coming weeks, our key areas of focus will be as follows:

• develop and disseminate a “care home preparedness checklist” covering all five support areas to assess current status and identify areas care homes need support with – early June 2020
• assess how many care homes are using staff who work in more than one care home – early June 2020
• confirm care homes payment arrangements for staff that are self-isolating; agree a consistent approach across all the care homes, in line with national guidance – end June 2020
• to expand and roll-out the work we have started in our older people’s homes into our mental health and learning disability settings; immediate priorities will be around testing and replicating the clinical “wrap around” support offer – over June 2020
• establish a weekly teleconference for mental health and learning development care homes, to highlight issues and provide support from NHS partners, including infection control– June 2020
• to implement virtual multidisciplinary teams in our older people’s homes - commencing from June 2020
• ensure clinical leads are in place for mental health and learning development homes – beginning June 
• agree and implement enhanced primary care support into mental health and learning development care homes – end June 2020
• develop and implement guidance around care homes residents that wander – mid June
• assess current level of take up in care homes of “train the trainer” infection control offer – end May 2020
• undertake on-site (where possible) an assessment of each care home to review design/layout of the building, and determine how this can be enhanced/maximised to support IPC management for example looking at zoning, cohort staffing etc. – end June 2020
• expand local testing offer into mental health and learning development care homes – end June
• explore and implement incentives to encourage staff testing – early June
• to continue to develop and deliver virtual training sessions to all care home staff, in line with training gaps that are identified by them and the wider partnership – ongoing
• undertake review of access to medical equipment and training in each of the care homes; determine what equipment is required, and support with procurement where required – end June
• to review the financial situation for all of our care homes, mid June 2020
• work with commissioners in other boroughs to ensure that the care homes support offer is in place where we commission placements – early June 2020

The Infection control fund (75%) will be used to support those actions above related to infection control. In addition to this we will have discussions with our providers and our partners on the use of the remaining 25% - options include further enhancement of work in our mental health and learning disability homes; and ensuring appropriate infection control measures are in place in our domiciliary care providers across the borough.

This report has been produced to give an overview of work the council is undertaking with partners to implement government guidance for care homes in managing the coronavirus pandemic.

Appendix

London Region Appendix

COVID-19 has provided an unprecedented challenge to adult social care. The challenge has been significant in London due to early and rapid spread of the virus, local patterns of deprivation, high levels of air pollution and the high proportion of ethnic minority populations in most London boroughs.

Across the Capital, local authorities responded to the challenge and our responsibilities under the Civil Contingencies Act by working together as LondonADASS and Chief Executives, alongside NHS partners to identify issues, galvanise responses and lead several pan-London initiatives. We brought our response co-ordinated together through the Strategic Co-ordination Group (SCG) and joint governance with NHS London.

Given the high rate of infections in the Capital, the fact we were ahead of the national curve and the difficult issues created by early national guidance, we believe that without collective action the impact on residents we support to live with support from the care sector and the number of care home deaths would have been significantly higher.

We are now focussed on continued monitoring of the adult social care market to respond to possible further peaks of COVID-19, as isolation rules are relaxed, and to suppressed non-COVID NHS demand. This includes support for older people, those with a learning disability, mental health needs and direct payment users. We will remain vigilant to potential future outbreaks and provider financial viability, ensure sustainable access to PPE and testing and continue to use data to support decision making.

Pan-London initiatives

The following gives a flavour of just some of the actions taken pan-London:

We worked with PHE London in March / April to develop consistent and up-to-date on-line training in infection control and rolled this out to care homes, supported by local follow up advice and guidance.

There was escalation from early April to advocate for regular testing of both care home staff and care home residents and for testing of people being discharged from hospital into care settings. We have contributed to London work on testing approach for care homes, alongside PHE. This was identified as a significant strategic risk.

Early escalations on the need for a sustainable supply of PPE led to the PPE task group, reporting into SCG on our response and highlighting this a strategic issue for both our own local authority staff and that of the provider market. This supported joined up NHS/Local Authorities systems for accessing PPE and, in addition, a London-wide Local Authority PPE procurement through the West London Alliance in response to unreliable national supply chains. At the local level, where PPE was available, commissioning teams distributed this directly to local providers based on detailed intelligence about infection and PPE supply levels for each care home.

Early identification of the risks to workforce were identified and on 10th April we launched Proud to Care London to support recruitment, DBS checking and basic training of care staff. To date we have had over 1800 registrations and of these 180 have passed to councils and providers, with excellent feedback about the calibre of the candidates being connected with work settings. It is also worth noting that we are reaching a new profile of carers – with 1/3 of applicants under the age of 30. We are now in the process of transitioning the Proud to Care initiative from an SCG sponsored workstream to LondonADASS, in order to further develop the model with the ultimate ambition of creating a Social Care Academy for London.

The risk of inconsistent clinical support to care homes across the Capital and the need for the NHS to step up was identified and led to a joint letter to ICSs and local systems from the Chief Nurse and lead Chief Executive 09th April to galvanise action. A weekly regional Care Homes Oversight group was established 07th May co-led by the Chief Nurse and LondonADASS Vice Chair.

The objectives of the Oversight Group are to:

• Oversee roll out of key elements of the primary and community health service-led Enhanced Health in Care Homes programme including, but not limited to, access to weekly clinical reviews, medicines optimisation and advanced care planning
• Identify opportunities to support staffing in the care home sector and coordinate any regional response, which may draw upon initiatives across the NHS and local government (Your NHS Needs You / Proud to Care)
• Continue to ensure that all residents are being safely and appropriately discharged from hospital to care homes
• Have oversight and assurance of care home resilience plans, responding to emergent challenges and supporting the care home community
• Have oversight of Regional improvement support, public health and operational challenges using system wide data sources including, but not limited to, outbreaks, mortality, workforce and access to training and clinical in-reach
• Have oversight of the Regional Test, Track and Trace (TTT) across care home workforce and residents, ensuring that ‘hot spots’ are identified and targeted in a timely manner
• Implement a ‘super’ trainer programme in care homes based on PHE’s recommended approach to infection prevention and control, PPE and testing

Engagement with residents and user voice is central and Healthwatch are part of the London Oversight Group to reflect people’s experiences. However, engagement largely takes place at local system level where the most meaningful relationships are in place.

We worked collaboratively with NHS colleagues on discharge planning safe pathways and co-ordinated work in STP/ICS sub regions to support development of discharge beds for COVID positive patients to prevent spread of infection.

DASSs in London have been able to assure themselves that core safety, human rights and safeguarding duties are being delivered when Care Homes are in lock-down without the usual footfall and community access to residents’ homes. Local mechanisms for safeguarding processes, provider concerns and quality assurance mechanisms have continued to inform work with providers in the sector. Regionally we have specifically worked with the Coroner and PMART teams to understand safeguarding concerns and quality alerts and respond appropriately.

We have worked in strong collaboration with NHS London and Carnall Farrar to build a demand and capacity model that is intended to support joint planning of health and social care at local authority, STP/ICS and regional levels into the future, populated by our market intelligence with shared understanding of assumptions driving the model. This included capturing additional social care capacity during ‘Surge’, so that any need for further accommodation could be met on a pan-London and sub-regional (STP/ICS) basis. Happily, as with the Nightingale beds, most of this was not required. However, the model will support tactical planning requirements over an 18 month period to support NHS London to return to its pre COVID-19 position.

Use of both the 18 month tactical planning tool and the suite of near term operational planning tools covering acute, community, social care and primary care will support both London region and each ICS to understand projected demand (non COVID-19 and COVID-19) over the next 18 months and the potential impact. Creating an overview of the whole system, we aim to ensure this tool supports planning together in equal partnership and safer discharge pathways.

Use of data and intelligence

Our response has been underpinned by data and intelligence. Support to the provider market and situation reporting into the London Resilience Forum was enabled by our existing London wide Market Information Tool (MIT). The tool was developed by LondonADASS to support the delivery of our Care Act duties and was quickly adapted to establish a comprehensive and up-to-date understanding of London adult social care markets (home care and care homes) during the spread of COVID-19 at local, STP/ICS and regional levels.

The daily survey includes information on:

• Prevalence of COVID-19 and associated mortality
• Actual and true availability of supply
• Discharges from and admissions to acute care
• Staff availability
• Details of PPE stock
• Access to testing

We prioritised older people’s care homes because we understood this was where the greatest impact and safety issues would be and because 30% of all older people care home placements are across borough boundaries, so collaborative work is essential. We started the care homes data collation mid-March and have a consistently high daily response rate. This reflects the leadership of borough commissioners working intensely with their providers and building these relationships through direct and often daily contact. These local relationships are realising ongoing benefits in relation to our statutory market management responsibilities and support to providers.

The MIT tool has produced:

• At borough level: Continuous, live access since 23rd March for borough commissioners to a detailed suite of reports allowing them to prioritise the local operational response, such as the delivery of PPE, ensuring appropriate staffing levels and providing Public Health infection control support.
• At regional level: Daily information cell SITREP indicators (including evidence based 7 day projection figures) for the London Strategic Coordination Group. Daily Market Intelligence Reports, produced jointly with the LSE, and circulated since 1st April to each DASS, and DPH across London. These reports have mapped trends at London, sub-regional and borough levels in key risks for care homes for older people, people with learning disabilities, those with mental health needs and home care providers.
• At ICS level: The detailed suite of reports and London analysis has been shared with NHS colleagues to co-ordinate and prioritise health and local authority support and interventions.

The data collected has been used to develop models identifying care home and local characteristics correlated with the spread of COVID-19, associated mortality, impact on care capacity and supply sustainability, access to PPE and care staff availability. These models have informed the targeting of support to care providers and, in partnership with LSE, emerging international evidence has been regularly shared with London DASSs since 04 April.

Overall, this evidence and analysis has underpinned our London-wide strategic and operational decisions and meant key issues were escalated to the highest level as early as possible.

Now that national data collections are established on a temporary basis and the London Strategic Coordination Risk relating to social care is stepped down, we are working with national colleagues to ensure a smooth transition to Capacity Tracker. We plan to do so in a way that does not compromise our responsibilities under the Care Act or the systems set up to support the critical incident response and continues to use the rich longitudinal evidence produced by the MIT to inform strategic social care decision-making across London boroughs.

Moving forward

We have reflected on the lessons learned about resilience and support to both care homes, and the care sector more broadly, over this period of intense activity. Much of this is reflected above in terms of the need for sustainable PPE and testing; streamlined and safer discharge processes; the need for consistent and integrated wrap-around clinical support in the community and the opportunities for joined up demand and capacity modelling to support whole systems planning.

Local Government has played a critical role in managing the UK’s response to Covid-19. Its wide range of responsibilities, from public health and social care through to bin collection and data analysis have all been key to ensuring that the UK has been able to manage the epidemic, and to sustain vital services.

Social care has played a particular role in supporting those in our communities who are most vulnerable and, as a nation, we have seen a renewed understanding of the importance of care and support to the development of a sustainable and safe society, alongside the critical treatment services that colleagues within the NHS provide.

In the first phase of the pandemic, due to its emergency nature, social care was asked to play a role in the national effort to protect the NHS from becoming overwhelmed in the event of a surge of demand. The policy of protection was successful, and the NHS was able to respond effectively to Covid without at any point becoming overwhelmed. Patients suffering from Covid 19 were all able to receive the treatment they required within a hospital setting.

Although the policy of protecting hospitals was necessary and successful, we were concerned that it was not broad enough and protecting the system of social care and health is a crucial priority as we move forward.

Now that we understand much more about the nature of the disease, those most likely to be affected and the appropriate protection and treatment options available, the social care community is able to be very specific about how best we can work collectively with colleagues across health and care to support and sustain the whole system through the next phase of Covid-19.

We recognise the risks to financial sustainability for some care homes and are already beginning to use our market insight to get a differentiated picture of levels of financial risk across the market. This, alongside a deep understanding of the quality of care homes in London, will inform local decision-making that drives value for money and the best possible outcomes and quality of life for residents.

We welcome the additional funding that Government has so far provided to support councils’ overall response to Covid-19, including adult social care, however we recognise that there still needs to be a sustainable funding solution for adult care services.

We need to expand and protect our workforce, so that they can continue their vital work maintaining people’s health and independence outside hospitals supported by their local communities.

We have demonstrated the value of local strengths and asset-based responses to support shielded and vulnerable groups in our communities and the case for joint investment as a critical part of our heath and care system to support and sustain this to ensure that residents are protected from the virus, and that their mental health and wellbeing is prioritised

We need to ensure that care homes and home care staff are able to provide safe, infection-free spaces for vulnerable people. This may mean zoning care homes in line with current clinical practice, and prioritising testing and PPE for homecare workers. This includes a clear national strategy on testing and re-testing for staff and residents.

We recognise that the response to the virus requires a system-wide approach. We will work with colleagues in health, the voluntary and community sector and our local communities to build effective system-wide, place-based responses. We recognise that we all work best where we plan and deliver together. We will participate fully in the development of effective response plans for the second phase of Covid-19, both regionally and in our local areas, and need to engage with partners from the outset of this process.

Our commitment in London is to ensure a smooth flow of our contribution from recent monies to our care home providers, alongside all the other support we offer, in a way that recognises that the care and support we provide to residents is to help them to live their lives safely and with high quality support, in their homes.

Care Home Action Plan Update

Further to the successful bid, we continue to work with the care homes and have updated our action plan to reflect our progress and our plans for the future.

• Learning Disability and Mental Health Care Homes Support Plan
• Older People Care Homes Support Plan

Paul Najsarek and Sarah McClinton

On behalf of London Chief Executives and LondonADASS