This is now my third article examining developing Government guidance and how it impacts the issue of admissions into care homes during the COVID- 19 pandemic.
Yesterday, the Social Care sector took centre stage at the Government daily briefing as Matt Hancock revealed a number of headline promises for the sector. More detail on these can be found in the latest Department of Health and Social Care guidance entitled “ COVID-19: Our Action Plan for Adult Social Care” (“the Action Plan”) published yesterday (14 April 2020).
This article will examine the key changes around admissions made by the Action Plan to the 2 April 2020 Guidance “Admission and Care of Residents during COVID-19 Incident in a Care Home”.
Previous Guidance
The 2 April Guidance had stressed that it was expected that residents would be admitted to Care Homes even if these patients may have COVID-19, whether symptomatic or asymptomatic. The Government position set out there was that “All of these patients can be safely cared for in a care home if this guidance is followed.” It set out to Providers how to care for 3 categories of COVID-19 Status:
- Resident has no symptoms of COVID-19;
- Resident has tested positive for COVID-19, is no longer showing symptoms and has completed isolation period; and
- Resident has tested positive for COVID-19, is no longer showing symptoms but has not yet completed isolation.
I set out in my previous article, that a fundamental flaw with that Guidance was that, although it stated “The Hospital Discharge Service and staff will clarify with care homes the COVID-19 status of an individual and any COVID-19 symptoms, during the process of transfer from a hospital to the care home”, it was widely known that testing of residents before admissions to care homes was not widespread or commonplace. Indeed the 2 April 2020 Guidance went on to state that “Negative tests are not required prior to transfers / admissions into the care home”.
I set out in my previous article that, in order for that Guidance to be effective, there must be testing. This is firstly so the Provider can know for sure which of the three categories above the Resident falls into to assess if they can provide the care required, and secondly because the scenarios in the 2 April 2020 guidance did not properly account for an individual’s COVID-19 status being unknown.
This was problematic because, even though an individual is not showing COVID symptoms does not mean they are not infected with the virus. The individual may never show symptoms, which, according to the 2 April guidance, would be the trigger to provide care in isolation, and without that isolation, that Resident could continue to spread the virus with a very vulnerable group unknowingly.
The previous guidance was also based on the false premise that all Providers have the facilities, equipment and staff to provide care in isolation. This is simply not the case.
The New Action Plan
The new Action Plan appears to address a number of these concerns:
It commits to the testing of all symptomatic residents in care homes being. Previously, only the first five symptomatic residents in a care home would be tested for the purposes of confirming an outbreak.
Fundamentally, in terms of admissions to care homes, the Action Plan is unequivocal that the Government “will move to institute a policy of testing all residents prior to admission to care homes.” That will begin with those being discharged from hospital and the guidance provides that “the NHS will have a responsibility for testing these specific patients, in advance of timely discharge”
At last, it seems that Providers are being given something to rely on to support their requests to NHS discharge teams for a test prior to the admission of a new resident.
That said, the guidance does foresee that there will be circumstances where a test result is still awaited and a resident is discharged pending the result. In these circumstances, the Action Plan recommends that the patient will be discharged, and pending the result, should be isolated in the same way as a COVID-positive patient will be.
The Action Plan also provides that, for people discharged asymptomatic into a care home, who will now have been tested, even if their results are negative the Government “still recommends” isolation for 14 days. This is actually a U-turn from the 2 April guidance. It provided that, If a resident had no symptoms of COVID-19 upon discharge, the care home should provide care as normal and only if they developed symptoms should care be provided in isolation. It further provided that the resident has tested positive for COVID-19, is no longer showing symptoms and has completed isolation period the care home should provide care as normal.
Another very important change for Providers introduced in the Action Plan is the Government recognition that not all Care Providers are equipped to meet the requirements to provide care to COVID residents in isolation.
Providers have been voicing concerns repeatedly about their inability to effectively isolate COVID positive (or COVID suspected) residents in the way envisaged in the 2 April 2020 guidance. This is due to the fact that many Providers simply to not have enough PPE, staff or appropriate facilities to do so or because the practicalities of the needs of particular groups (e.g. advanced dementia or complex learning disabilities) make social distancing impossible.
The Action Plan pledges that the Government are “determined to make sure discharges into nursing or social care do not put residents currently in those settings at risk”. The Action Plan finally recognises that isolation can only take place in a care home “able to meet that requirement.”
Whilst the Action Plan sets out that “a small number of people may be discharged from the NHS within the 14-day period from the onset of COVID-19 symptoms needing ongoing social care” it recognises that, despite the terms of the 2 April 2020 Guidance and the statement contained therein that “All of these patients can be safely cared for in a care home if this guidance is followed”, that only some care providers will be able to accommodate these individuals through effective isolation strategies or cohorting policies.
The Action Plan is clear that:
“If appropriate isolation/cohorted care is not available with a local care provider, the individual’s local authority will be asked to secure alternative appropriate accommodation and care for the remainder of the required isolation period”
The Government expects that the Local Authority will draw on the £1.3 billion funding made available to support enhanced discharge from the NHS and that the Local Authority will work together with the NHS to put this approach into practice, in accordance with the NHS Discharge requirements.
It is hoped that this change means that it is now for individual Providers to decide whether a new admission will be clinically safe for the individual resident, existing residents and staff. This will require an assessment of the Provider’s ability to meet social distancing guidance and the availability of staff and other resources such as PPE. As set out in my previous 2 articles this simply has to be the case in order to allow the Provider to ensure compliance with its ongoing obligations which include compliance with Regulation 12 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
In the event that a Provider is not satisfied that they can facilitate such an admission then it appears it is for the NHS to look to the Local Authority for an alternative placement. If and how this will work in practice remains to be seen.
However, this position in the Action Plan is a welcome a step back from the 2 April guidance which attempted to effectively force Providers to accept new admissions of residents to Care Homes regardless of COVID-19 status on the false premise that all Providers were appropriately resourced to put appropriate isolation measures in place. This was met with anger, disappointment and fear in the sector that it would lead to the spread of COVID-19 throughout care homes.
Many have argued that these and the other measures announced yesterday for the Care Sector are too little too late and that this is reflected in the increase in the numbers of deaths in care homes from COVID-19 (which themselves do not properly form part of the Government statistics).
The Government denied a failure to prioritise the needs of the Care Sector through the pandemic thus far. Matt Hancock responded to criticism to that effect stating that the Government has been repeatedly updating guidance for the sector according to the progress of the disease.
Many will disagree and feel that it is completely unacceptable that the Social Care Sector has had to wait until now for a comprehensive Action Plan which has in fact been a reactionary measure in the wake of intense criticism from the sector and the media about the way Social Care has been treated up until now.
It remains to be seen whether the commitments set out in the Action Plan will actually be delivered.
The action Plan can be accessed in full here.
