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Care Inspectorate: Report on the Medicine Improvement Project

The Care Inspectorate has published the final report from their medicine improvement project.

The Care Inspectorate’s vision is that every person in Scotland receives high-quality, safe and compassionate care from care services that are continually improving.

The management of medicines in care homes for older people, and its effect on resident’s health and welfare, remains a concern.

In support of this vision and with the help of Scottish Care, the Care Inspectorate undertook a project with 10 care homes, aiming to reduce medicines issues using quality improvement tools.

The care homes’ commitment to improve was reflected in their positive relationships with each other and the Care Inspectorate. All homes embraced the use of data over time to drive forward behavioural and system change, and most homes reduced defined medicines issues by a significant amount, despite the interrupted nature of the project. The interventions used to achieve this should offer a good starting point for any homes looking to improve their handling of medicines to support residents’ health and wellbeing.

Elements of the framework used in this project may also offer benefits to both the sector and us as the regulator in the post Covid-19 scrutiny landscape.

This report was prepared by Dr David Marshall Health Improvement Adviser, Care Inspectorate, who would like to offer special thanks to Scottish Care, the managers and staff of the homes involved, and the individual Care Inspectorate inspectors of the homes for their support and enthusiasm for this project.

The report is available here.

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Scottish Care responds to the Adult Social Care Winter Plan

Scottish Care welcomes the first ever Winter Plan for Adult Social Care as an indication that there is now a recognition of the importance of social care for all citizens. We are pleased to see that there is a particular emphasis upon collaboration and look forward to future plans more directly engaging with and involving those with operational and frontline responsibility.

We are pleased to see within the Plan a real sense of value of and an emphasis upon the dedicated and professional social care workforce who not just during COVID-19 but throughout the years have been professional and highly skilled in supporting individuals regardless of locations.

Details of the Winter Plan:

We welcome the additional £7 million allocated to Nurse Directors to enable IPC support and training and want to underline the critical and distinctive nature of IPC in care homes and community settings. We will work closely to ensure that IPC training and models are appropriate to the setting and that we do not simply embed acute hospital and NHS based IPC practice. Such adoption of IPC has not only to be context specific but enhancing of the rights and autonomy of individual care home residents or those who live in their own homes.

The majority of care homes already undertake a daily review of COVID-19 symptoms, and we note this in the Plan and look forward to sharing the clinical experience of care home staff with the Clinical and Professional Advisory Group.

We support the imperative around the flu vaccination whilst urging all stakeholders to learn the lessons of what has at times been an ineffective and haphazard implementation of the vaccination strategy, failing at times to recognise the distinctive realities of care at home and housing support staff and the skills and experience of care home nursing staff. We look forward to closer collaboration as we plan the roll out of the COVID-19 vaccine.

The care home sector is fully supportive of ensuring that visiting guidance is implemented in a manner which maximises safety and reduces risk. Providers recognise and value the truth that family members are intrinsic to the mental and emotional wellbeing of residents. However, there is both an understandable desire on the part of providers to protect residents and a fear about introducing infections. We acknowledge that the introduction of a robust and effective testing system will help to allay the fears of providers of care. This urgently needs to include family members alongside staff, and all those who visit care homes for whatever reason, in a manner which is as timely and effective as possible in terms of testing access and turnaround of test results. As a whole system we need also to address the challenges brought about by emerging difficulties in gaining insurance and indemnity, the stresses and overwork created by Operation Koper, and the capacity of a stretched workforce to support visiting in practical ways.

We note the evidence of staff movement in relation to outbreaks. We recognise the desire to create cohorts of staff regardless of settings. Achieving this outcome will not be easy. Individuals who work in social care are amongst some of the lowest paid within our society and they frequently have multiple jobs not because they want to but because they need to. This is especially true in homecare where we are already noting a drift from full-time employment to part-time working because staff are exhausted by the efforts of the last few months.

Great care needs to be taken that to ensure that restricting the right to employment and requiring individuals to isolate for 14 days between employment does not disproportionately penalise individual workers.

In addition, there has to be a realistic appreciation that there is a limited supply of workers. Before the pandemic providers of care – regardless of sector – struggled to recruit, most especially nursing staff. We have all to work closely at local level to ensure that there is adequacy of workforce supply to ensure safety and quality practice. The roles involved are highly skilled and cannot simply be undertaken by individuals without experience, skill or training.

Further the creation of any legislation which effectively limits employment opportunity within a sector which has struggled to recruit, and which is likely to be negatively impacted by future immigration restrictions, will require to be carefully considered and thought through. The consequences of disproportionate restriction regardless of the robust grounds for their introduction may be hugely damaging.

We note the allocation of £50 million to meet these proposals but want to understand how this figure has been calculated and whether it is sufficient, what it will be used to pay for and how we will collectively compensate workers and organisations faced with additional restrictions on staffing.

Testing remains critical. In addition to our comments above we want as a sector to see urgent and immediate plans as to how care at home and housing support staff will be prioritised for asymptomatic testing. It is now seven months since we called for this to become the norm and we still have not seen this commence.

In the community we welcome the emphasis on ensuring people remain independent and at home for as long as possible. With others we continue to urge the re-introduction of care packages for those who have not been supported for a long period of time. We remain concerned that there needs to be significant improvement in practice around communication and information for homecare providers when an individual with COVID-19 is released from hospital. We continue to be concerned that effective winter care in the community will not be achieved as long as some local authorities continue to insist on 15-minute visits during which personal care and other tasks are required and the staff member has to don and doff PPE in a safe manner. Such restrictive packages of care together with the electronic monitoring of homecare staff should stop. They are hardly illustrative of our shared aim for Fair Work.

We welcome the continuation of the Social Care Support Fund which goes some of the way towards plugging the unfair terms and conditions within publicly commissioned social care contracts.

We are also grateful for the continued commitment to the supply of PPE where providers are unable to access these through business as usual routes, and especially in light of the reprehensible re-introduction of VAT on the 1st November.

We look forward to continuing to work with colleagues in the roll out of digital devices to care homes to improve connection and welcome the commitment of £500k to support this work.

Any Plan is only as effective as the commitment and resource to enable it to be enacted. Social care providers continue to prioritise not just keeping people safe and well but ensuring individuals achieve their fullest potential and live life to the full. We agree with the aims of the Plan and commit to demonstrating integrity to resolve challenges in a supportive and empathetic manner in the months ahead.  Its success will be premised on true and meaningful partnership with social care providers at national and local levels.

The Adult Social Care Winter Preparedness Plan 2020-21  is available here.

Find out more about the Plan on the Scottish Government website.

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Resources from Covid-19 Surgery with PHS – 03 November

Huge thanks to Dr Jenni Burton and Fiona Mackenzie from Public Health Scotland for coming onto our members surgery today (03 November) to talk through the report that was recently published by PHS on Discharges to Care Homes from NHS Scotland Hospitals. This report is available here.

We hope that members found this session useful, presentations slides and the recording of the surgery can be accessed via the buttons below.

For further discussion and queries, please contact:

[email protected]

Watch recording here
Access the presentation slides here
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Job Opportunity – Independent Sector Lead: Scottish Borders

INDEPENDENT SECTOR LEAD – Scottish Borders

PARTNERS FOR INTEGRATION AND IMPROVEMENT

SCOTTISH CARE

Health and Social Care Integration

£43,622 (pro rata) per annum – 14 hours per week

Fixed term contract funded till March 2021 (initially) subject to funding may be extended to March 2022

Do you have an interest in improving the quality of care, can you COLLABORATE, INNOVATE AND COMMUNICATE, and would you like to join a successful, committed and highly motivated team? This could be the opportunity you have been waiting for.

We are seeking to engage an Independent Sector Lead to support the Integration of Health and Social Care in the Scottish Borders.  Hosted by Scottish Care and working closely with care providers and partners, the post involves ensuring sector involvement in the delivery of the integrating of health and social care in Scotland’s HSCPs

The post holder must be highly motivated, be able to use initiative, possess excellent communication and networking skills, demonstrate success and experience working at strategic level with policy makers, providers, regulators, people supported by services and carers. Qualifications and experience at a senior management level would be a significant advantage.

The post holder will be expected to create and support significant collaborations across the independent care sector while contributing to the development of new care pathways which will result in the delivery of improved outcomes for people who access care and support. The post holder will ensure the Independent sector’s contribution is fundamental to integrated services and transformational change and be able to evidence their impact. The role requires considerable and skilful collaboration with our key partners in the NHS, Local Authority, Carers, third sector organisations and other forums.

The post is home-based with travel where necessary, based and is hosted by Scottish Care.

To request an application pack, please contact Colette Law at Scottish Care by email [email protected]

Closing date 4pm on Thursday 12th November 2020.  Interviews will be held by video conference – date to be confirmed.

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To Absent Friends – a festival to remember in times of covid

A collective of charities and interested organisations will shine a light on bereavement this week, as they launch the To Absent Friends festival 2020.  Heralded as a ‘people’s festival of storytelling and remembrance’ the festival takes place from 1-7 November across Scotland – online, in public spaces and in people’s hearts and minds.

The festival will see the launch of the To Absent Friends Cookbook – a collection of recipes and stories for those loved and lost. (https://www.toabsentfriends.org.uk/cookbook/) The virtual book has been put together by Cruse Bereavement Care Scotland, Macmillan Cancer Support, Marie Curie, Scottish Care, Scottish Partnership for Palliative Care and Sue Ryder.

“Working to support people who are bereaved, we see how important it is to make time in our lives to remember people who have died.  2020 has brought loss and grief to many, while also preventing people from getting their usual support from friends and family.  We’ve seen how hard this has made life for people who are grieving.  The To Absent Friends festival is an opportunity and an excuse for people to take a moment in their busy lives to remember people who have died, whether recently or long ago.” said Nicola Reed of Cruse Bereavement Care Scotland, who shared a her Dad’s special stew recipe for the Cookbook.

The To Absent Friends Cookbook brings together stories of people who have died, alongside recipes that have special significance for the people they left behind.  A mother’s recipe for stovies, a friend’s delicious traybake, a much-loved daughter’s favourite pie.

“When we were compiling the cookbook, we noticed that most of the food people connect with loving memories is delicious, homely and comforting, like a shepherd’s pie, or a simple occasion cake.  And the stories that come with the recipes are a delightful mix of love, laughter and tears. It is particularly poignant to be publishing this book this year, in times of covid-19, when so much loss has been suffered by so many.” said Rebecca Patterson, Director of Good Life, Good Death, Good Grief.

The launch of the To Absent Friends Cookbook is just one of many activities taking place as part of the festival this week, as communities from across Scotland hold local remembrance events. With most face-to-face gatherings out of the question this year, much is taking place online and planners are finding innovative ways of creating time and space for remembrance.

For example people living in Willowbrae, Edinburgh are creating a ‘wanderland’ of home window displays in memory of people who have died; Action Porty are providing individual kits to enable households to have beach bonfires of remembrance; and North Argyll Carers Centre has invited bereaved carers to contribute to a beautiful light installation which will be suspended within North Argyll Carers Centre to be viewed from the windows during the festival.

“I think that this year most of us have been craving human connection.  And that is what this festival is about – connecting with each other over shared memories and stories.  Perhaps this year, when it is hardest to organise a festival, it is more needed than ever before.”  said Richard Meade, Head of Policy and Public Affairs Scotland at Marie Curie.

To Absent Friends is a reminder, an opportunity and an excuse to create time and space to remember the important people in our lives who have died.  Festival organisers are inviting members of the public to get involved, even at short notice, from the comfort of their armchair.

They invite people to visit the festival website www.toabsentfriends.org.uk to share their memories on the online wall of remembrance, add songs to the Remembrance Playlist, or tweet #ToAbsentFriendss throughout the week. A full list of this year’s events is available here: https://www.toabsentfriends.org.uk/blogs/festival-events-2020/

For more information, contact Rebecca Patterson on [email protected] or find out more via the website www.toabsentfriends.org.uk

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Car sharing guidance – 30 October

We have created a handout that providers can download with guidelines on car sharing.

The guidance says:

  • You must not share a vehicle if either the driver or passenger is feeling unwell or has any symptoms of Covid – however mild- or if either has been advised by Test & Protect that they are a contact of a confirmed case
  • Wear a face covering which fully covers your nose and mouth (this is mandatory on public transport)
  • Limit the number of different people you share transport with – if you regularly travel with others, try to share with the same people each time if possible
  • Limit the number of persons within the vehicle- Driver and 1 passenger only, where possible in a standard car
  • The passenger should sit in the back seat on the left hand side to maximise the physical distance between people in the vehicle
  • Avoid touching your face covering
  • Wash or sanitise your hands before and after your journey and if you are the driver you should encourage passengers to do likewise
  • Use windows and/or vents to encourage fresh air circulation inside the vehicle and removal of ‘stale’ air. Avoid using air recirculation settings on your car.
  • If you regularly share a vehicle, clean vehicle touch points (door handles, steering wheel etc) at least daily with a detergent wipe or similar
  • Please do not attend work/share a car with a person who has Covid-19 symptoms or who has been informed via test and protect contract tracing that they are a contact of a confirmed COVID-19 positive case.
Download guidelines
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Scottish Care statement on discharges into care homes

In the early days of the pandemic the wider societal and political concern was the risk that the NHS acute sector would not be able to deal with a massive increase in patients requiring treatment for COVID19. It was at this time that there was a concerted focus on creating capacity within NHS hospitals by ceasing routine non-essential treatments, by maximising the availability of respirators, etc. At the same time there was a push to discharge individuals who were fit for discharge either to their own homes or to care homes.

In ordinary circumstances an individual is discharged when they are clinically fit. Before Covid-19 this was often a process which was delayed as a result of the non-availability of care home beds. This was not because the beds were not available but because funding from public authorities was not sufficient to enable these transfers to take place.

Even before Covid-19 there were circumstances where the eagerness to discharge from hospital in some locations had led to a strain or breakdown in relationships with the care home sector. The most commonly cited instance for these tensions was where a clinician considered someone capable of being supported in residential care, whereas after they were discharged it became clear to care staff that they required nursing and not residential care.

Before the pandemic, therefore, the process of clinical discharge into care homes was one which was not always smooth and frequently problematic. As a result, there was often a local distrust in the discharge system and process.

This level of challenge was reflected in the Clinical Guidance issued by the Scottish Government on 13thMarch which stated:

‘Transitions from hospital.

There are situations where long term care facilities have expressed concern about the risk of admissions from a hospital setting. In the early stages where the priority is maximising hospital capacity, steps should be taken to ensure that patients are screened clinically to ensure that people at risk are not transferred inappropriately but also that flows out from acute hospital are not hindered and where appropriate are expedited.’ (page 4)

Because individuals were not routinely tested at the point of discharge at this stage of the pandemic, despite the requests of the care home sector at the time, there was a real concern that people who entered care homes might be infectious. It should also be noted that the Guidance from Health Protection Scotland issued on 12th March made no reference to any process to be undertaken during admission from hospital.

Scottish Care’s CEO, Dr Donald Macaskill held a meeting on the 18th March with the Cabinet Secretary for Health and Sport and highlighted that care home providers were expressing concern over discharge procedures and that some were refusing to admit new residents. During the meeting he stated that the previous relationships between the acute and care home sector had sometimes not been as good as they might have been. As a positive result of the meeting the Clinical Guidance was revised and re-issued on 26th March.

This Guidance made the process of admission much clearer. It states:

‘4.2 Admissions/transfer from hospital to care home facilities

HPS updated guidance states that if the individual is deemed clinically well and suitable for discharge from hospital, they can be admitted to the facility after:

  • appropriate clinical plan.
  • risk assessment of their facility environment and provision of advice about self-
  • isolation as appropriate (See NHS Inform for details). (page 4)
  • there are arrangements in place to get return them to the facility

Decisions about any follow-up will be on a case by case basis.

If a patient being discharged from hospital is known to have had contact with other COVID-19 cases and is not displaying symptoms, secondary care staff must inform the receiving facility of the exposure and the receiving facility should ensure the exposed individual is isolated for 14 days following exposure to minimise the risk of a subsequent outbreak within the receiving facility.

Individuals being discharged from hospital do not routinely need confirmation of a negative COVID test. Facilities will be advised of recommended infection prevention and control measures on discharge. It is recommended that this includes a documented clinical risk assessment for COVID-19.’ (pages 4-5)

This general approach was followed which meant that there was a presumption that it was not necessary to test an individual prior to them being discharged and admitted to a care home. This is stated clearly in the Health Protection Scotland Guidance of 17th April:

‘As part of the national effort, the health and care sector plays a vital role in accepting individuals who have COVID-19. Such individuals can be safely cared for in a health and care facility, if this guidance is followed.

Individuals who have been confirmed as having had COVID-19 but no longer have symptoms and have completed their isolation period prior to arrival, whilst still in hospital, home or another facility, can have care provided as normal.’

Scottish Care during this period continued to call for mandatory testing of individuals at the point of discharge whilst at the same time recognising the importance of residents returning to their care home and the strategic need to ensure that people were not unnecessarily delayed in hospital.

We further recognise that from 21st April it became a requirement for all patients being transferred from hospital to receive a negative test. Before this date, no such requirement was in place.

Before 21st April it is impossible to determine the extent to which care providers were made aware of the testing status of individuals upon admission to care homes.

Today’s report is an extremely thorough statistical analysis based on a diverse set of data and a triangulation exercise and presents a conclusion that hospital discharges per se were not a significant factor in outbreaks in a care home. It does state that the admission of some residents in some instances would statistically increase the risk especially if they had been untested.

More reassuring is the analysis that the use of testing reduces the risk of an outbreak in a care home.  The report’s recommendation on the importance of discharge planning involving the person themselves, their families and care homes as partners, and on the need for clear communication of an individual’s testing status, is welcome.

More work needs to be undertaken to better understand the reasons why the size of a care home is proving to be a factor in relation to outbreaks, including what particular factors relating to size have an impact.

Dr Donald Macaskill, the CEO of Scottish Care states:

“Today’s report makes for detailed and robust reading and yet it is only part of the story. The statistical analysis is thorough and highlights that the risks to care homes in terms of outbreaks are related to the size of a care home. This is because larger care homes tend to be nursing homes, dealing with more frail residents and those living with dementia; they have larger numbers of staff members and environmentally because of size present greater IPC risks.

What is missing amongst all the data and statistics, the numbers and charts, is the story of those who cared for residents in our care homes. Their experience of discharge, of residents arriving home or coming for the first time to the care home, is missing and requires to be told. Some of our members and staff who work in care homes in a few cases believe that Covid-19 was introduced into their care home community as a result of discharges. I hope the researchers can take some time to listen to the experience of staff in care homes where there have been significant outbreaks. At the moment we have one side of the story, what is missing is the frontline experience of our care sector and its staff, the voices of those who received care and their families.  

At the start of the pandemic all the emphasis was on the preservation of the NHS. Our politicians and medical advisors stood in front of posters which read ‘Protect the NHS’. The care home sector and its workforce played its part in that protection, and can be assured that in the majority of instances that support through enabling people to come home or be admitted, was not a significant risk factor for outbreaks. However, we need to ensure that where people are convinced there was a direct relationship between discharge and outbreak that this belief needs to be investigated.

We should have initiated testing for all discharges much earlier than we did. The report makes it clear that there are real benefits from this testing process.

We know those of older age, the very frail and those living with multiple co-morbidities remain at particular risk – we all of us need to do everything we can to protect our most vulnerable, regardless of where the live or are cared for.

We expected and still do expect that care homes, which are places of contact and community, become isolation units for those leaving hospital or coming in from the community, almost to become specialist infection control environments against the most virulent disease we have witnessed in decades. Care homes, regardless of the sacrificial dedication and skill of staff, cannot completely protect against the virus. It is quite clear that during the summer we had virtually no outbreaks but as transmission rates increased in the community, then the risk of asymptomatic spread into our care homes has increased at a disturbing level.

The report is a reminder of the pain we have all endured. Its insight should become the energy to ensure that the whole health and care system really does support the care home sector in the weeks ahead, that it becomes each of our responsibilities to protect by our everyday action, putting the needs of the residents rather than the protection of any system or organisation at the heart of that shared focus.”

Public Health Scotland has published its findings on discharges from hospitals to care homes during the COVID-19 pandemic. The report is split into two sections: one presents statistics on people aged 18 and over who were discharged from a hospital to a care home between 1 March and 31 May 2020, while the other defines and describes care home outbreaks of COVID-19 with an analysis of the factors associated with those outbreaks, specifically including hospital discharges.

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Urgent request for care homes regarding CHAT

Dear Care Home Providers/Managers

Some of you may be aware that collaborative work is underway to progress of the implementation of the CHAT (Care Home Assessment Tool) Covid app. In line with this, we are requesting assistance to inform the progress of Phase 2 work. It would be helpful if care home providers could share the escalation tool carers currently use for recording the deteriorating residents in residential homes. We are aware that care homes with registered nurses will use tools such as News and Restore 2 to support this. We appreciate that there is likely to be variation around this and would appreciate your input to inform this work so we can consider the best triage tool to support carers to escalate and get medical support. If you could contact me re this directly on [email protected] as soon as possible to allow us to determine the best way forward.

Many thanks,

Jacqui Neil

Transforming Workforce Lead