Independent report

Chapter 8.2: care homes

Updated 10 January 2023

Introduction

The COVID-19 pandemic had significant impacts on residents, staff and carers across care homes.^{[footnote 1]}, ^{[footnote 2]}, ^{[footnote 3]} In this pandemic, care homes were a substantially higher risk setting for COVID-19 as so much of the risk was in older people, in particular the most vulnerable older people, and spread occurred most readily in indoor environments. This was not always the case in previous pandemics and epidemics, and could look different in a future pandemic. Experience from COVID-19 will be most relevant in pandemics where the elderly are particularly at risk, and where respiratory infection and close contact are important routes of transmission.

In addition, COVID-19 (in common with many other infectious diseases) often presented atypically in the older population, and so there needed to be increased vigilance and a lower threshold for investigation. One of the single biggest reasons for needing long-term care is dementia which is also an important risk factor both for SARS-CoV-2 transmission and poor outcomes. There was a need to reduce risk of transmission among this clinically vulnerable cohort, while continuing to support residents physically and mentally and deliver care services over a prolonged period.

In the UK, the adult social care sector covers multiple types of setting, but here we focus on residential and nursing homes (care homes) as this is the adult social care sector most significantly impacted in this pandemic. The vulnerability of the care home sector to COVID-19 was similar in most high-income countries with large populations of older people. This was flagged as a risk early on in the pandemic, though many countries struggled with the best way to respond and it took longer than anybody would have wished to respond effectively. In the UK, as in many comparable countries, the care sector is complex, large, varied, fragmented and in places was fragile even before the pandemic. The care homes sector alone currently has 7,500 separate providers with 15,500 homes of varying sizes (1 to 250 beds) caring for around 500,000 older and working-age adults (though older people outnumber working-age people by a ratio of 2.5 to 1). There is a high turnover of care workers, and many work in multiple settings or for agencies.^{[footnote 4]}, ^{[footnote 5]}

Residents in care homes typically have multiple needs and require a range of frequent close care and support interactions – for example, support with cleaning themselves, getting dressed or going to the toilet. This care is provided by staff trained in adult social care, with clinical input provided by on-site nursing staff (nursing homes only) and visiting health professionals. The complexity and severity of medical and nursing needs is even greater in nursing homes than in residential homes. Spread of less severe but highly infectious pathogens such as norovirus and influenza has been known to present challenges to the resident population.

Initial priorities prior to the introduction of a vaccine concentrated on trying to prevent ingress and minimise transmission, as treatment options for infection were limited. However, reducing risk of transmission in care homes involved some of the most complex trade-offs of risk to individuals of any part of the pandemic. These included considering the needs and rights of individuals as well as those of the wider resident population. This in turn meant balancing the risk of COVID-19 outbreaks in a very vulnerable group with maintaining staffing, access to healthcare, close contact needs of residents, visiting by relatives and friends in what are often the last months of life, and dignity and quality of life among a group with high prevalence of dementia. For example, it became clear early on that there was a need to reduce transmission from staff moving between care homes, but an intervention that reduces staffing levels in an already pressured sector could in turn harm quality of care and therefore introduce different risks to residents. Stopping visiting by relatives reduced infection risks to all residents, but inevitably reduced the quality of life of residents and their families. There were existing issues with staffing levels and capacity in the sector prior to the pandemic. Other factors such as limited sick pay (making it financially difficult for staff to take time off if they needed to self-isolate) were common. It was therefore evident from early in the pandemic this was one of the most at-risk sectors but also one where mitigation of risk was not easy in a fragmented sector operating under multiple pressures.

Many staff came from communities experiencing higher transmission and so were also at heightened risk of exposure in the community despite their extensive efforts to reduce risk for residents. This epidemiological trend introduced both transmission risk and a risk to staffing levels in the event of large-scale absences due to COVID-19 sickness. The close links between both staff and visitors and their local communities meant that transmission risks in care homes generally reflected transmission risks in linked communities – and so it was essential to reduce community transmission in order to support vulnerable populations within care homes.^{[footnote 1]}, ^{[footnote 6]}

These are just some examples of issues explored in more detail in working papers by the Scientific Advisory Group for Emergencies (SAGE) Social Care Working Group (SCWG) referenced in this chapter, and others.

This chapter reviews key public health interventions in UK care homes during this pandemic, first setting out an overview of the epidemiology of the pandemic in care homes as this is important context for interventions.

Epidemiology of the pandemic in care homes

In spring 2020, there was widespread recognition that ‘3 epidemics’ were occurring:

• in the community
• in hospitals
• in care homes – with high care home transmission following around 2 weeks after high community transmission

Outbreaks in care homes were closely correlated with community prevalence throughout the pandemic, and there is genetic evidence that the majority of outbreaks were introduced unintentionally by staff members living in the wider community.^{[footnote 7]}, ^{[footnote 8]}, ^{[footnote 9]}, ^{[footnote 10]}, ^{[footnote 11]}, ^{[footnote 12]}, ^{[footnote 13]}, ^{[footnote 14]}, ^{[footnote 15]} Care homes were, at this point, largely closed to visitors, but ingress of infection through staff living in the wider community and moving between care homes was readily amplified by the close contact networks required in the provision of care.

Figure 1: schematic showing the potential routes of ingress of COVID-19 into care home settings^{[footnote 16]}

Description text for Figure 1^{[footnote 17]}

There was potential exposure to COVID-19 in care home settings from:

• core staff
• visiting professionals
• visitors of residents
• residents making outside trips
• new admissions from the community
• residents returning from hospital
• new admissions from hospital

Larger care homes were more badly affected, which likely reflects their greater number of points of ingress as well as greater risk of resident and staff movement. Staff shortages, worsened by the pandemic, exacerbated risks of staff movement between care homes. Interventions to mitigate this through asymptomatic testing and avoidance of cross-deployment were only partially successful at times of high community prevalence.^{[footnote 18]}

Epidemiological and genetic evidence from across the UK suggests that for COVID-19 while some care home outbreaks were introduced or intensified by discharges from hospital, hospital discharge does not appear to have been the dominant way in which COVID-19 entered most care homes.^{[footnote 19]} Prior to testing being widely available, the risk of keeping care home residents in hospital at a time of increasing nosocomial infection risk needed to be balanced with the risk that they might already have acquired COVID-19 and introduce it to the care home. Nevertheless, hospital discharge to care homes connects 2 high-contact environments, and it was and should remain a high priority for preventive actions in similar pandemics.

The impact of this pandemic on care homes

The first and second waves of the COVID-19 pandemic had a profound impact on the health of residents of care homes for older people, with high attack rates and a large number of deaths as shown for England in Figure 2 below.^{[footnote 20]} In this pandemic, residents of care homes for older adults were particularly vulnerable due to their age, the presence of multiple high-risk co-morbidities, and the transmission potential inherent in frequent close physical contact through care (which resulted in large numbers of outbreaks).

The measures taken to reduce transmission, like reductions in visiting, also impacted residents – in particular loneliness, isolation and deconditioning as well as stress and distress for residents, staff and loved ones.

Staff in care homes were shown early in the epidemic to have high levels of COVID-19 antibodies in early studies, consistent with high infection rates.^{[footnote 21]}, ^{[footnote 22]} Vaccine efficacy data subsequently confirmed a high prevalence of pre-existing antibodies, and by the end of waves 1 and 2 at least a quarter of staff and a third of surviving residents had already been infected.^{[footnote 23]}, ^{[footnote 24]} Infections in care home staff were closely related to community prevalence, a relationship which continued as vaccines and boosters were rolled out and reduced the risk of severe outcomes. A number of risk factors for infection were also over-represented in care home staff, such as socio-economic status (see Chapter 2: disparities).

Figure 2: registered deaths and deaths with COVID-19 on the death certificate taking place in care homes (nursing and residential) in England from week ending 27 March 2020 to week ending 18 August 2022 ^{[footnote 25]}

Note: due to limited availability of testing during the first wave, not all deaths attributed to COVID-19 were confirmed by diagnostic testing.

Description text for Figure 2^{[footnote 26]}

Timeline is from March 2020 to August 2022.

The graph tracks 2 things: registered deaths in care homes and deaths showing COVID-19 on the death certificate. These show as 2 lines on the graph. The pattern for both lines is a steep rising curve in late March 2020 followed by a sharp tailing off, then another peak in March 2021, dropping again to a fairly stable line up to August 2022.

Registered deaths are consistently around 2,000 deaths above deaths showing COVID-19 on the death certificate but they broadly follow the same pattern.

The risk of severe outcomes varied over time, with a decline in case fatality as vaccines were rolled out and immunity increased due to a combination of vaccination and infection. It also probably reflects the impact of high early mortality among the most vulnerable residents.

Emerging understanding of case fatality rates by age and other factors such as dementia, physical frailty and co-morbidities informed differentiated approaches, particularly in care homes for people of working age in which residents have different patterns of needs and comorbidities to older age homes. In homes for people of working age, case fatality was much lower than care homes for older people, but in some groups (such as those with Down’s Syndrome) there was a high risk of severe outcomes.^{[footnote 27]}

Public health interventions in care homes

Relatively enclosed communities such as care homes broadly face 4 kinds of hazard from infectious threats like COVID-19:

• ingress of infection through connection to community and other care settings
• transmission via contacts between staff and residents
• outbreak in closed, densely networked settings
• severe outcomes among residents vulnerable through age, frailty and co-morbidity

This hazard framework is generalisable to other pandemics and epidemics, although specific aspects may be less relevant. For example, testing may be less important in circumstances when symptoms of an infection are highly specific and transmission tends to occur after they first appear.

Addressing these hazards required both non-pharmaceutical interventions (NPIs) and pharmaceutical interventions (PIs). It is important to emphasise that these interventions were implemented by multiple partners within and beyond the care home system to protect both individuals and collective cohorts of residents, staff and visitors. They involved public health, social care and medical care delivery arrangements.

Non-pharmaceutical interventions

As noted elsewhere in this report, PIs were not available in the early stages of the pandemic and so the focus was on NPIs initially. These focused primarily on reducing ingress and transmission of SARS-CoV-2 in care home settings to reduce the frequency and size of outbreaks.

As the first wave rose, NPIs included new and more stringent use of personal protective equipment (PPE) by care home staff and reduction or prevention of visiting, which was sometimes implemented by care homes in advance of official guidance to this effect. Shielding, an option for similarly vulnerable people living at home to reduce their contact with others, was not feasible. The appropriate use of PPE was an important part of mitigating the risks of close contact needed in care homes. This will be explored by the public inquiries on COVID-19 and so it is not explored in detail here, except to highlight some important points for a future CMO or GCSA to be aware of:

• although PPE had been used in the care sector before the pandemic for specific activities and hazards, universal use in the pandemic required updates in knowledge, skills and practices in care homes in line with practices previously standard only in specific acute healthcare settings
• appropriate provision of supplies and training on universal PPE used to support care homes in their role was complex in a fragmented sector with multiple differently sized homes and a mobile workforce; the sector and supporting organisations such as local authorities made huge efforts to rapidly roll out mutual aid networks and training provision to address this issue

Avoiding the deployment of non-permanent staff who might move between homes and ensuring sick pay for affected staff sought to reduce risks of ingress, while higher staff-to-resident ratios and cohorting staff to avoid caring for both infected and uninfected residents helped reduce the risk of transmission from staff to residents.^{[footnote 28]}

Testing was also an important intervention in this pandemic. It was not a routine intervention prior to the pandemic and was initially limited – scaling of systems did not meet demand at the outset of the first wave (see Chapter 6: testing). However, as testing became more widely available in April 2020, care home staff and their household members with symptoms were given access. This helped identify and exclude the staff most likely to be infectious at a given time. This was followed by routine asymptomatic testing of care home staff. Over summer 2020, as more testing capacity became available, whole care home testing was implemented to assess the force of infection in care homes once an outbreak was identified, to guide infection prevention and control (IPC) measures and to judge when an outbreak was successfully controlled and allow some response measures to be stood down.

There were some important developments during this pandemic for care home response management. In particular, data systems and reporting were key, and many new systems and processes were set up across the UK. In Scotland in late 2020, for example, management data (such as on staffing, screening, PPE, IPC and escalation points) was captured daily and published internally for care homes, health boards and health and care partnerships to review and use. It was modelled on a hospital ward safe staffing tool with additional information such as on home capacity, resident or staff test positivity or symptoms and numbers of affected residents. The tool supported multidisciplinary teams working across multiple care homes to provide further supervision if needed, highlight where training in IPC might be needed (and ensure it was delivered), track PPE supply needs and redeploy staff from the acute sector to care homes in times of high pressure. Local health board nurse directors provided clinical governance to review these activities, aligning governance in a previously fragmented sector and giving an overview of frequent challenges through regular ‘look back’ exercises. There is no formal evaluation of these changes in the sector, but aligned governance and systems to track need and provide mutual aid were undoubtedly helpful in managing the care home response in this pandemic and likely to be so in a future one.

In recognition of the clear correlation between care home size and risk of outbreaks and poor outcomes, segregation of larger care homes into smaller sealed units with discrete staffing teams was also deployed in periods of higher prevalence. It was hard to evaluate the impact of these changes and we are not aware of any comprehensive evaluation of how effective they were – but the logic behind such measures is sound.

Finally, ventilation was a key NPI for care homes in this pandemic. While many IPC measures are well understood in the health and adult social care sectors, little scientific attention has to date been given to air quality in care homes as a mitigation and key element of IPC, and it is not an aspect of the environment well understood or easily controlled by carers. A good understanding of the ventilation characteristics of care homes and other closed settings is key to mitigating the impacts of acute respiratory infections generally, and of future pandemics. The importance of this may go beyond viral respiratory pathogens. There is however a tension in that very cold or very hot environments are particular risks to elderly patients, so optimising ventilation has to be balanced against thermoregulation.

As the pandemic progressed, vaccines became a primary mitigation, reducing both severe outcomes and infection risk (see Chapter 8: pharmaceutical interventions). High levels of vaccine uptake among residents (typically 95% among older adults) following prioritisation of care homes for vaccine rollout led to a marked reduction in hospitalisations and deaths, as shown in Figure 2.

Building the evidence base

The UK scientific response to the emerging high impact of COVID-19 on at-risk care settings required fast-paced, collaborative and multidisciplinary research programmes at scale.

The Vivaldi study, for example, established a network of over 300 care homes to gather evidence on a range of issues in care homes from early in the pandemic.^{[footnote 29]} This included a cross-sectional survey showing an increased risk of resident infection associated with use of non-permanent staff, not paying sick pay for staff, new admissions to the care home, and difficulty in isolating residents.^{[footnote 30]}, ^{[footnote 31]} These risks were often in tension with the economic and workforce features of the sector, including staff turnover and vacancy rates, along with frequent use of non-permanent agency staff.^{[footnote 32]} This meant that prevention of staff movement could risk reducing care to some residents. They also had to be balanced with other issues such as the importance of having visitors to resident wellbeing; there were difficult trade-offs in managing transmission risk within homes.

The Easter 6 (later named the ‘London Care Homes Network’), meanwhile, used detailed genomic testing and contact tracing analysis to understand transmission networks in care homes. These bespoke studies have provided rapid and high-quality evidence on a range of topics including vaccine efficacy, the emergence of variants, and their comparative outcomes, and the high prevalence of antibodies to SARS-CoV-2 in both residents and, to a lesser extent, staff early in the pandemic.^{[footnote 33]}, ^{[footnote 34]}, ^{[footnote 35]}, ^{[footnote 36]} Beyond the Vivaldi and ‘Easter 6’ networks, much of the evidence on the impacts of interventions on care home residents, positive and negative, has been indirect. Evidence drawn from modelling studies and existing studies of community or hospital populations of older adults highlighted the vulnerability of older people to physical deconditioning and the impact of ageing on vulnerability to other infections.^{[footnote 37]}

To interpret study outputs and provide science advice informing social care policy decisions, the SCWG complemented work conducted by the Scientific Pandemic Influenza Group on Modelling Operations (SPI-M-O) to understand the impact of SARS-CoV-2 on vulnerable populations and settings such as care homes. Modelling approaches were used to understand the key determinants of ingress and transmission of SARS-CoV-2 in high-risk adult social care settings. A key focus was ongoing assessment of effective options for the most appropriate testing and isolation regimens for care home staff and residents to mitigate the risk of transmission of SARS-CoV-2 and to reduce hospital admissions and avoidable mortality due to COVID-19.

There remain, however, important gaps in the evidence. Always a challenging setting for research, infection control policies have made care homes even less accessible during this pandemic. Evidence on best practice to address social isolation and loneliness in care homes is still emerging and not yet synthesised or well understood,^{[footnote 38]} while there remains a striking lack of directly gathered evidence from residents on their perceptions and preferences. Importantly, understanding of the wider impacts of NPIs needs further development. Their impact in care homes for older people is likely to be different from the general population due to the high prevalence of cognitive impairment, some degree of deafness, and physical frailty. There are not yet high-quality studies which allow comprehensive quantification of the balance of benefits and harms of different NPIs in a care home setting.

Reflections and advice for a future CMO or GCSA

Point 1

Residents of care homes for older adults are very likely to be at high risk of serious disease in any respiratory disease epidemic.

Measures to reduce ingress to care facilities (via staff or visitors) and minimise transmission while maintaining quality of care will be a high priority.

Point 2

NPIs that reduce personal contacts, particularly isolation from family and loved ones will have a considerable impact on residents’ (and families’) quality of life.

Balancing the benefits and harms is not straightforward. The length and extent of limits on visiting (inward and outward), on social interactions of residents, and the use of masks at all times by staff during the COVID-19 pandemic were unprecedented in care homes. Useful measures to mitigate the harms of isolation included use of technology to support social contact and designated ‘essential carer’ visitors even during outbreaks (with appropriate protective measures and supports).

Point 3

The control of transmission in care homes also depended on alignment with wider public health, social care and healthcare systems.

Preventing ingress into care homes proved extremely difficult during periods of high prevalence in the community. High case rates in hospitals required careful management of discharges into care homes. The structure of the care sector presented challenges: there is enormous diversity of facilities and many staff move from one facility or care role to another within the same week or even day. The adult social care workforce, although trained to provide care, lacks the status of registered professionals and is relatively poorly paid and insecurely employed, with high vacancy rates and poor sick pay provision.^{[footnote 39]}

Point 4

The value of reliable and comprehensive routine population and health data describing the population living and working in residential care to inform policy decisions and evaluate the impact of interventions cannot be overstated.

Routine and bespoke data sources enable calibration of interventions to vulnerability and impact, through an understanding of:

• ingress routes
• attack rates
• case fatality
• hospitalisation in different groups of residents^{[footnote 40]}, ^{[footnote 41]}

Testing early and often is of course key in understanding (and responding to) ingress routes, although if testing capacity is limited there will need to be careful prioritisation of available capacity.

Point 5

Advice from behavioural and social science was essential in informing good practice in the support and management of care staff and in protecting residents.

This highlighted, for example, that there was a risk of stigmatisation and fear, and the need for financial and other support for staff when isolating.^{[footnote 42]}

Point 6

Research and innovation to improve care homes’ resilience to respiratory and other infections is needed and could inform, among other things, building regulation and best practice.

There are challenges conducting research in care homes, particularly during a pandemic, with limited evaluative evidence available on intervention impacts.^{[footnote 43]}

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