Care homes action plan: final update

In July 2020, the Deputy Minister for Health and Social Services set out six themes that encompassed work being undertaken with our partners including Regional Partnership Boards who had identified specific support they would deliver to care homes in their areas. These themes were:

1. Infection prevention and control
2. Personal Protective Equipment (PPE)
3. General and clinical support for care homes
4. Residents’ well-being
5. Social Care workers’ well-being
6. Financial sustainability

The Care Homes Action Plan set out our high-level actions to ensure the care home sector was well supported throughout the winter, learning lessons from the COVID-19 pandemic. This plan was a component of our overarching Welsh Government Winter Protection Plan. 

The table below summarises achievements against the high level actions in the plan and highlights ongoing and future work. 

Care home providers and the people living and working in care homes have faced an unprecedented challenge over the last 12 months. It has been an exceptionally difficult and distressing time for all involved.  We are so grateful to everyone who has played a part in responding to the COVID-19 pandemic and very much hope that the actions set out in this action plan have made a difference to all those that live and work in our care homes in Wales.   

The challenge is by no means over. We know we cannot look to eradicate COVID-19 in the near future, so we must learn to live and work alongside it for some time to come. We are committed to continuing to work with the care home sector and wider public services as we take steps to begin to rebuild our services, learning the lessons from COVID-19, and capitalising on the opportunities and changes we have seen during the last year.

Actions

We will develop a clinical contingency template and will provide further advice and support for individual care homes to complete the template, to enable their whole team to prepare for the management of any further infections in the home. The template, which will include environmental and staff management (minimising staff movement), personal protective equipment (PPE) and testing of care home residents and staff will enable care homes to consider their own resident group, staff group, environmental layout and service delivery. 

Care home residents and staff prioritised for vaccination.

Summary of achievements

We worked with colleagues from the Nosocomial Transmission Group to develop an Infection Prevention and Control (IPC) Checklist for the management of COVID-19 in care homes. The document is intended to support care home providers in reviewing IPC arrangements within their individual care homes. The checklist was sent to Directors of Public Protection Wales (DPPW) in January to be circulated to care home providers in their areas

To support providers to complete the checklist for their homes, an IPC webinar was held by Welsh Government and Public Health Wales colleagues on 3 February. This event gave further details about the IPC checklist, summarised key IPC procedures and provided an opportunity for care home providers to ask questions.

A video of the webinar has been produced as a training and information aid for care home providers.

All care home residents and staff were offered vaccination as the first priority of the vaccination strategy. Frontline health and social care staff; those 70 years of age and over; and clinically extremely vulnerable individuals were offered the first dose of the vaccination by 12 February, which was in advance of the target date of 15 February for groups 1-4.

Action

We will continue to work with the Nosocomial Transmission Group, chaired by the Deputy Chief Medical Office.

Summary of achievements

Regular communication and support for care homes has been essential throughout the pandemic. We have consistently worked with the Nosocomial Transmission Group to raise awareness and provide training, guidance and support to care homes.

The Infection Prevention and Control (IPC) training Task and Finish group which reports to the Nosocomial Transmission Group has completed work on developing joint health and care standards for IPC. These standards will be launched at the end of March 2021. Work continues to develop a suite of IPC training resources for the workforce across health and social care. The Welsh Government has supported the appointment of a post to be based in Health Education and Improvement Wales to manage the strategic future planning and education of the specialist IPC workforce.   

The Nosocomial Transmission Group (NTG) recognises the need to have assurance that environmental cleaning in all social care settings is being managed in accordance with current UK guidance for COVID-19. 

We therefore issued Key standards for Guiding Environmental Cleanliness for Care Homes in March adapted from the cleaning standards developed and published for the hospital setting in December 2020.  

The document contains a series of recommended standards and principles that will help to support a best practice approach that adult care homes can adopt or refer to in order to develop their own local policies or plans. This is in order to prevent and minimise transmission of COVID-19 in these settings.

We also introduced the COVID-19 statutory sick pay enhancement scheme on 1 November. This provides funding for care workers, ancillary staff and agency staff in care homes to receive full pay when they should stay off work to protect residents in the following circumstances:

• experience possible symptoms of COVID-19
• receive a positive test result
• contacted by TTP

Required to self-isolate as household member has symptoms or tested positive
Providers can claim the cost of employer’s National Insurance and pension contributions, and a small administration fee, to support the scheme. Towards the end of last year we held several large online events to explain and respond to queries about the scheme, which is managed by local authorities on our behalf.

Further guidance was issued and further online events with local authorities, providers, agencies and unions to further embed the scheme were held. Ministers have agreed to extend the scheme to the end of September 2021. While take up has been lower than expected – this is dependent on several factors which could not be accurately predicted (including COVID-19 prevalence rates and choice of the alternative self isolation support scheme). We have contacted stakeholders again to raise scheme awareness as a result of the extension of the scheme.

Action

We will set out the ongoing arrangements for testing care home residents and staff in line with scientific evidence as it emerges.

Summary of achievements

On 23 December Ministers published the ‘Coronavirus plan: alert levels for social care’ which has provided a framework for testing and infection prevention and control measures in line with each of the 4 alert levels. We continue to develop and refine testing across the social care sector and will need to review our approaches as community prevalence reduces and restrictions begin to lift. In addition to the weekly asymptomatic PCR testing that has been well established in care homes since June 2020 and the outbreak testing responses, we have also rolled out the following testing programme for care homes:

• LFD testing for visitors to care homes including visiting professionals
• enhanced twice weekly LFD testing for care homes staff
• PCR and LFD testing for larger supported living settings (that operate more like care homes) as well as visitor testing
• PCR testing for children’s homes as well as visitor testing

Since early January positive test results in care homes across Wales have continued to sharply fall. This is testament to the hard work of care homes, their staff and community health protection colleagues in effective use of testing, PPE and infection prevention and control measures.

In January ministers announced a funding package for care homes to support the enhanced testing and testing for visitors. These funds are being distributed via the Local Government Hardship Fund and include a one off payment of £103 per resident with each care homes also being able to claim up to £600 towards the cost of creating a safe testing area. Plans for ongoing financial support for the sector post March are currently being explored.

Action

We continue to supply PPE free to the social care sector.

Summary of achievements

Our position remains strong as we continue to supply PPE free to the social care sector. We will ensure sufficient PPE continues to be made available, free of charge, for all care homes in Wales during the pandemic.

Action

We are exploring the PPE procurement arrangements across the social care sector to better understand supply patterns and products to ensure longer term security of product availability.

Summary of achievements

Public sector partners including the Association of Directors of Social Services Cymru (ADSSC) have met regularly with Welsh Government to consider policy, demand, procurement and distribution of PPE.

A Service Level Agreement (SLA) was put in place between the Welsh Local Government Association (WLGA) and NHS Wales Shared Services Partnership (NWSSP) to provide PPE for Social Care within local authority areas including private, independent and third sector providers. The SLA continues to deliver sufficient, timely, free PPE for all social care providers.

The SLA will be reviewed to ensure that it continues to operate sufficiently between all partners and can be updated if needed to take account of changing circumstances over the course of the pandemic.

Action

We are considering whether a digital recording system will aid the request and receipt of specific PPE items.

Summary of achievements

We have continued to work with NHS Wales Shared Services Partnership (NWSSP) on the implementation of a nationwide electronic stock management system called Stockwatch for the provision of PPE for the social care sector. This enables real-time stock levels to be monitored and used to inform regular deliveries. The system l helps us ensure that local authorities can maintain their distribution of appropriate PPE supplies to social care providers at sufficient levels to protect staff and the vulnerable individuals they care from COVID-19. 

We will continue to support Joint Equipment Store staff directly as well as via local authority contacts to ensure that all effectively use the e-system.

Action

We will review the general and clinical support provided to care homes for adults in Wales between July and September this year to identify areas of best practice and lessons learned ahead of winter pressures.

Summary of achievements

We commissioned Professor John Bolton, a consultant in adult social care, to undertake a rapid review of care homes’ operational experience during the COVID-19 pandemic between July and September. A national report was published in October 2020 to ensure learning was shared across Wales.

Recommendations resulted in the development by Regional Partnership Boards (RPBs) of their own bespoke care home action plans to ensure support is tailored to meet local need.

The 7 regional care home action plans have shown a significant shift in the level of support that has been provided to care homes throughout the pandemic. There is increased partnership working and communication with care homes with the sector represented at a strategic level within many RPBs.

Many RPBs reported that supporting care homes to access and operationalise the large amount of information and guidance that they have been provided with has been of huge benefit and has been welcomed by care home staff. The regions also have worked to ensure staff have a clear understanding of procedures and escalation processes.

Sharing examples of good practice/learning has also proved helpful. Partnership working was seen as essential in tackling the issues in relation to COVID-19 given the multiple agencies needed to support care homes. Ensuring this positive approach is maintained and built upon was seen as being key.

Peer support, access to expert advice, guidance and basic training have all been highlighted as valuable. In many cases this has been as simple as acting as a ‘sounding board’ for care homes to test their intentions or providing answers to straightforward questions. 

Recognising infection prevention and control as ‘everybody’s business’ has been an important message shared across the regions. The vaccination programme, whilst not removing the need to ensure effective prevention and control measures are in place and adhered to, is seen as having a significant impact, not only on supporting the stability of the sector but also on a sustainable workforce. 

The on-going pandemic and the reactive demands on service delivery in supporting care homes with testing and infection prevention and control in particular, has clearly impacted on the ability to take planned work forward in a timely way.  

There is also acknowledgement of the need to continue to support the sector financially both now and in the future, including work on sustainable fee levels and regional modelling of market stability.  

Action

Support for care homes is noted as a key milestone for NHS quarter 3/4 reporting under the primary and community care priority, which is one of the six priorities identified by Health Board Directors of Primary and Community Care and agreed by the National Primary Care Board and the Welsh Government’s Primary and Community Care Recovery Oversight Group.

Summary of achievements

The Care Home Framework was issued to Health Boards in October 2020 following wide stakeholder engagement. The priority of this work was reinforced by Welsh Government via the Delivery Milestones that were issued at the same time. This set out the requirement for Health Boards to self-assess against the Care Home Framework and provide an immediate position against the Framework. There was a further milestone that set out the expectation that Health Boards would set out a longer term plan to adopt, adapt or justify by the end of March 2021.

On 2 March 2021, a questionnaire was circulated to seek initial views from a range of staff in Health Boards on the progress made to date in implementing the Framework and to quantify any early benefits. It is intended to use the feedback from the survey to refine, if required, the framework going forward.

Action

We will ensure care home residents have the opportunity to share their experiences of living in care homes during the COVID-19 pandemic.

Summary of achievements 

We considered a range of reports and information gathered such as those from the Older Person’s Commissioner for Wales, Care Inspectorate Wales and other stakeholders to understand residents’ experience during unprecedented lockdown measures. Based on this analysis we asked Age Cymru, All Wales People First and Voices from Care to engage with older people, younger adults and children who live in care homes to ask them about their experience during the pandemic and, in particular, what has supported their wellbeing during this time.This engagement has shown that:

• residents are missing visits
• visitor and volunteer support have been missed
• the effect of deaths in care homes has been very tough for both residents and staff
• spirits have been eroded by the length and severity of the restrictions
• residents are scared of the virus
• resident’s usual wellbeing routines have been broken
• technology has helped
• a sense of purpose has helped
• the pandemic has strengthened staff and resident relationships
• the role of the activity coordinator for raising moral has been important

As the pandemic and the ongoing restrictions continue to affect the lives of people living in care homes, we have explored how we can meaningfully continue this project to hear from more residents about their experiences of the pandemic in order to support their wellbeing as part of this process, inform policy development and develop good practice.

Funding will be made available to continue this work via a project entitled 'Tell Me More', which aims to engage with residents in care homes, enabling them to share and document their experiences as part of a creative and collaborative project.

It will also provide care home providers and staff with the tools to hold sensitive and effective conversations with their residents as part of their role in reviewing the quality of care of their services.

We will work with partners to produce a good practice guide to promote well-being which takes into account what matters to care home residents, based on their own experiences.

Action

We will ensure care home residents are supported to maintain contact with their friends and family. We will continue to keep our care home visitor guidance under review, making changes as necessary.

Summary of achievements 

We are aware that the restrictions on visits in particular have been extremely difficult for residents and their loved ones. The decision to restrict visiting was not taken lightly and was considered necessary during the peak to protect people from the risk of COVID-19.

Following the Deputy Minister’s Written Statement on 4 March, the First Minister confirmed on Friday 12 March that routine indoor care home visits by a single designated visitor could resume from Saturday 13 March onwards.

The Welsh Government care homes visiting guidance was updated on 12 March to support this change. This is in addition to visits in visitor pods and other visiting arrangements which are being supported.

Public Health Wales has produced guidance on risk assessments for visits to and from a care home in order to support providers. We held two webinars organised by Care Inspectorate Wales (10 and 11 March) and a recording is available on the Welsh Government You Tube channel. frequently asked questions collated from the two events have been collated and published on CIW’s website.  

We have provided 100 visiting pods, free of charge to care home providers for a 6 month hire period. We have also funded the hire of 55 visiting pods via the Local Government Hardship Fund for providers choosing to make their own arrangements.

To support residents to connect with their loved ones in other ways we funded Digital Communities Wales (DCW) to provide 1066 devices on loan to 590 care homes across Wales. Digital Communities Wales has published a blog highlighting the progress of the scheme.

DCW reported that the devices were primarily used to help residents stay in touch with friends and family, for virtual GP appointments, taking pictures to support GP consultations and for staff completing online training modules.

The case studies showed the positive impact the devices had on the residents, as they were used to come up with new activities, host quizzes, virtual concerts and look at old photos. The scheme has highlighted some issues, such as poor connectivity in some care homes, as well as a need to support staff with digital skills and confidence. We are working with DCW to help address these issues. We will continue to work with our stakeholder group to keep our care home visiting guidance under review and continue to promote a rights-based approach to visiting to ensure the balance is struck between protecting residents from COVID-19 and promoting the health and well-being of care home residents through vital contact with loved ones.

Action

We will ensure care home residents receive the care and support from professionals in the most appropriate way, either via technology or in person. 

Summary of achievements 

GP support has been enhanced by the 'Attend Anywhere' video consultation service which is available free of charge for widespread adoption in secondary care across Wales, including care homes.

The Care Homes Directed Enhanced Service (DES) was introduced in July 2020 to refocus GP support to care home residents during the pandemic. The main aims of the DES were to:   

• optimise access to primary medical care for care home residents
• enable urgent access to primary medical care advice for care home staff  
• continue provision of pre-emptive proactive and anticipatory care 
• promote a high quality consistent approach across health boards whilst at the same time being flexible enough to be adopted by clusters or individual practices 

85% of practices across Wales have signed up to the DES.

There has been a mixed picture of support across Wales but anecdotally we are aware of examples where GP practices have stepped up and supported homes and the residents during the pandemic.  

There is, however, the need to improve the understanding from care homes of what they should expect from their GP and so as part of the evaluation of the DES this year we will consider how communication could assist with understanding the new approaches to accessing GP support.

Action

We will work with partners to identify and share good practice.

Summary of achievements 

The Cwtch project has offered a platform for care homes to share best practice and self-manage some of the challenges of providing care through the pandemic, as well as offer peer support. 

We have facilitated a series of care home collaboration meetings for professionals supporting care homes to come together to share practice, avoid duplication, complement one another’s work, identify gaps and work together to develop solutions. 

Action

We are continuing to develop a broad range of provision from online and virtual face to face support to suit the variety of ways that staff may prefer to seek support at this sensitive time. We will publish the range of support available to social care staff on the Social Care Wales website alongside the existing offer of learning and improvement resources. Materials for distribution at care homes will be included.

Summary of achievements

Details of the emotional wellbeing support available to social care workers was collated and a road map to signpost social care workers to specific resources was published on Social Care Wales’ website. 

An Employee Assistance Programme providing health and well-being support, including one-to-one counselling for all social care staff across the sector was launched in early December. This scheme is being managed by Social Care Wales as part of its wider package of wellbeing support for the workforce.

We will continue to promote the availability of the package of wellbeing support to social care workers and their employers through a series of mailings of promotional materials (both electronic and traditional) and webinars.

Welsh ministers have announced a second bonus payment of £735 that will be payable to health and social care workers, which will include all care home staff. This is in addition to the scheme in 2020 that provided £500 to care home staff. Both schemes are to recognise and reward the commitment of staff during the COVID-19 pandemic.

Action

We are monitoring the implementation of the COVID-19 workforce risk assessment tool for social care workers providing seminars to support its use over the summer. 

Summary of achievements

An All Wales COVID-19 Workforce Risk Assessment Tool has been developed which helps workers consider their personal risk factors for COVID-19 and suggests how to stay safe. Support for the social care sector to use the tool has included good practice webinars, a social care champion’s network, frequently asked questions and animation. We will continue to evaluate the use and effectiveness of the tool via the First Minister’s COVID-19 Social Care Implementation Group.

Action

We will work with our partners to identify any further specific support required for our valuable social care workforce.

Summary of achievements

A wellbeing network, made up of key stakeholders from across the sector, has been established, coordinated by Social Care Wales. 

The wellbeing network meets monthly and continues to identify support that may be needed for social care workers.

Action

We will consider the specific costs care home businesses have incurred together with the measures and actions that were effective in alleviating financial pressure.

Summary of achievements

We considered the specific costs care home businesses and other adult social care providers have been experiencing in responding to the pandemic.

In response, we quickly put financial support in place, through the Local Government Hardship fund, to enable Local Authorities to support providers to meet these costs. Using this mechanism, we have provided more than £88m to the sector to 15 January with provision extending to the end of the financial year. In addition to supporting the costs of additional staff and general provision through a flat rate uplift, this mechanism also included an element to support Local Authorities in responding to unexpected pressures for providers within their areas to ensure continuity of provision during the pandemic.

We also provided an initial £22.4 million to Local Health Boards to similarly provide support for the additional costs in relation to healthcare that care homes and other care providers faced to the end of September. We then extended this provision, with up to a further £22.4million made available for Local Health Boards to continue this support for the remainder of the financial year.

Recognising the effective support mechanisms provided through the Local Government Hardship Fund, £206.6 million was announced in the Welsh Government’s final budget for 2021-22 to enable the extension of the Local Government Hardship Fund for a further 6 months. This extension includes support available for social care.

£3 million was provided through the Local Government Hardship Fund for a pilot project to enable Welsh Government to hire visitor pods and provide them directly to care homes or to reimburse providers making their own visiting pod hire arrangements.

We also provided over £3 million through the Fund to specifically support care homes with the additional costs relating to enhanced staff and visitor testing. Plans for ongoing financial support for testing within the sector post March are currently being explored.

Action

We will review the range of support and funding made available to care home businesses through a variety of mechanisms across Welsh Government departments and the impact they have had on improving sustainability during the COVID-19 pandemic.

Summary of achievements

In addition to the financial support made available via the Local Government Hardship Fund there is a range of other financial and support mechanisms in place. These include:

• Nearly £1m in grant funding via the Economic Resilience Fund to support businesses forced to temporarily cease trading. Economic Intelligence Wales (EIW) have been appointed to undertake an impact evaluation of the ERF. The evaluation will include a survey element and a follow on impact and conclusion evaluation later in 2021 and early 2022.
• Business Wales, the Welsh Government’s free bilingual business support service, is available for businesses and entrepreneurs and provides access to a wide range of business support, advice and information. Business Wales continues to offer support to businesses during the current crisis and beyond with post COVID-19 support.
• The £100m Development Bank of Wales COVID-19 Wales Business Loan Scheme (CWBLS) was available for a limited period and provided working capital to businesses experiencing cash flow difficulties as a result of the pandemic. The CWBLS formed part of the wider Welsh Government Economic Resilience Fund and by the end of July over 1,300 businesses accessed loan facilities of just over £92m.
• The Development Bank continues to offer a portfolio of funds relevant to businesses at different stages of their development and growth.
• £100m funding made available through the Transformation Fund for projects that demonstrate integrated models of health and social care. The mid-point evaluation suggests that the Transformation Fund is one of several funding streams that RPBs are utilising in their attempts to integrate health and social care services and there is a strong case for a more system-wide approach to future funding in order to lessen administrative and reporting burdens and to clarify the overarching strategic aims which funding is aiming to achieve.

Feedback and evaluation to date suggests that this additional funding has played a key role in enabling services to continue operating and indeed there has been growth and new care services registered in some cases. 
 
We will continue to monitor the financial pressures experienced by care homes and other adult care providers. Lessons learned from the evaluations underway of the use of these funds will assist consideration of long term measures to improve the sustainability of the sector.

Action

We will review the experience of organisations which established temporary services to provide additional social care surge capacity and identify lessons on issues such as cost and accommodation management. 

Summary of achievements

We have reviewed the experience of organisations which set up temporary, emergency residential care to respond to predicted pressures. Five local authorities developed additional provision. We have worked with them to understand the lessons learned on cost and accommodation management. These included the need to have a project plan in place and support from a range of professionals such as building services, health and safety, budget team, IT, HR; the requirement for staffing and a skilled home manager to run the service which can be time consuming and requires additional time and capital to engage back fill arrangements. Consideration also needed to be given to whether to purchase or lease/rent and borrow.

Action

We will consider the experience of any care homes that required contingency support to continue operating. We will develop a decision tree tool for those at risk of business failure or closure to assist in identifying and resolving key issues.

Summary of achievements

The additional funding provided by Welsh Government to support the financial sustainability of care homes during COVID-19 includes an element to enable local authorities to assist care homes with the financial consequences of voids they may be experiencing as a consequence of COVID-19. 

A decision tree was developed and issued to Directors of Social Services to support their care home contingency planning. Similar action was undertaken by health boards in relation to specific contingency planning for care homes with nursing. 

Local authority and health board contingency planning has shown a clear approach across Wales to supporting care homes to remain operational during the pandemic wherever possible and that systems are in place to identify care homes who are experiencing difficulty.  

Feedback indicates the importance of having clear escalation procedures in place and a robust process in the event of provider failure.  

The development of a guidance document on Contingency Planning for care homes based on learning from the Incident Management Teams and giving examples of good practice to help care home with their planning was also highlighted as valuable.

There is clear evidence of key partners working in much closer collaboration and this approach needs to be built on as we start to think about recovery.