Coronavirus (COVID-19) care home outbreaks - root cause analysis: progress report November 2020 to September 2022

3. Data landscape and Digital infrastructure

The RCA reported on the challenges of the data and digital environment facing care homes with some care homes having weak digital infrastructure and infrequent experience of continuous reporting on key IPC measures. While there was challenges, the report also noted the enthusiasm of the sector to use data to identify risks and drive improvement.

Recommendations:

3.1 Incident Management Team (IMT) systems need connected within and between boards to enable outbreak management and network analysis to be further enabled

3.2 Intelligence sharing across the system of national organisations supporting the pandemic needs strengthened to inform national action planning in support of local needs.

One of the challenges identified with reporting of outbreaks was the different systems in operation across Health Board areas and the inability for these to connect to one another in a timely and meaningful way or to link to care homes. Information governance was also highlighted as a barrier to data sharing.

Similarly, the ability for the local Health Protection teams to identify individual COVID-19 cases in residents and staff to trace back to an individual care home is problematic. There was an effort at the start of the pandemic to create a linked file in PHS which would identify residents with a care home flag at individual level so any positive COVID-19 tests could then be identified. However, this was incomplete as it required personal information and the Community Health Index (CHI) number for linkage. However, care homes did not have access to it for staff or residents so had to get in touch with GP practices/other health services to quickly compile which unsurprisingly resulted in incomplete data fields. Similarly, many staff working in the sector are from oversees and may not have a CHI number. Incomplete personal information and a lack of CHI made it difficult to identify with ease staff vaccination levels.

With regard to residents the prime issue is that the CHI Institution flag is not complete and not all care homes are flagged. The flag also relies on GP registered change of address so there is often a delay in this being changed and temporary residents are likely to be missed. The delay has lessened during COVID-19 as PHS are now getting updates weekly rather than monthly on CHI. Unfortunately, the flag only tells you that this is a resident not which care home a person resides in.

Identifying staff in testing/vaccination/health records is much more difficult as there is currently no national comprehensive care home workforce data source. The SSSC workforce data does not include registered nurses and other staff groups and NMC registration body for nurses does not hold information about non-nursing staff.

Progress

Throughout the pandemic, the CI continued their practice of sending all notification information about outbreaks to local public health teams. This ensured that information that was received was shared and that local teams had the information on outbreaks that was notified to the CI , including suspected and confirmed outbreaks of covid. This provided details of individuals and a direct link to care home.

Public Health Scotland have been working with Directors of Public Health (DPHs) through a short life working group to make recommendations on consistent data fields and reporting systems with a view to standardising outbreak reporting. The recommendations from that work will be published shortly.

Work has also commenced on attaching a Unique Property Reference Number (UPRN) to care home flag in PHS^[12] which will help identify the actual care home of residence. This effort needs to continue to ensure that for COVID-19 and other public health purposes that there is a robust mechanism to capture care home residents in national data sets.

In addition, we need to be able to ensure we have improved information on the workforce at care home level which would benefit public health response in terms of testing and vaccination but also quality and safety more generally. The latter is at present difficult to achieve as the registered data that SSSC hold is not routinely linked to health data. The Framework for Healthcare in Care Homes^[13] ("Health Framework") which was published at the end of June 2022 contains nine recommendations on data and digital that recognises the fundamental role this enabler plays in improvement for residents and staff.

3.3 The TURAS safety huddle system should consider wider winter preparedness and broader IPC needs as part of planned future developments and how the system might move to be used for local improvement

3.4 Support in building capacity and capability for data systems to be used by care home staff for quality improvement is required

The Scottish Government have run training sessions when the SHT was first launched but those modules were not included in education/training material and did not meet the requirements of different needs for different parties to improve understanding of the importance of data for care homes, how to input, how to use for improvement.

The RCA report commended the SHT for its ambition and ability as a platform for quickly enabling for the first time standardised information on key safety indicators in response to the pandemic. The report also supported its development for sustained improvement going forward. This sentiment was also strongly echoed in the Independent Review of Adult Social Care.^[14] The latter recognised the acute need for sustainable improvement in collaboration with the sector and national bodies and commended the SHT for being an important step to realising that vision.

To strengthen the use of the SHT, especially given the fact that care home staff were not all used to regular data reporting of this nature or improvement methodology, the RCA recognised that care home managers and staff needed support.

Progress

Care homes were extremely compliant with the SHT, which is not mandatory, throughout the height of the pandemic from its inception to August 2021 with the percentage of care homes consistently reporting at around 90%. The return rate began to decline in May 2022 to around 80% in part due to care homes not seeing the value of the SHT given that many of the COVID-19 measures have been paused or relaxed.

The SHT is under review (July 2022 onwards) to ensure it meets the needs of providers/users and reflects present and future pandemic/endemic status. This review aims to determine its future frequency of reporting and usage requirements, alongside, considerations of potential evolution 'post-pandemic' to serve as a supportive improvement tool beyond COVID-19 reporting. This review is due to report in 2023 and will consider:

a) The short term immediate future for the tool –COVID-19 focus and actionable information gathered, especially in relation to winter planning and supporting care homes/local partners.

b) The long-term and evolving the SHT to support improvement in line with the recommendations of the RCA, IRASC and Health Framework.

At this stage in the pandemic, it is recognised that ongoing work is required to foster continued understanding and of the value of the SHT approach..

A refreshed National Digital Health and Care Strategy^[15] was published in October 2021 which details the overarching/strategic approach to digital across the health and social care sector. It recognised the importance of sustaining the innovation that was demonstrated through the pandemic and provided a vision and principles in data. Work is also progressing on a national data strategy for health and care with three high level aims:

• to empower the people of Scotland to have greater access and control over their health and social care data,
• to empower those delivering health and social care services to have the confidence and ability to gather and share data to improve services
• to ensure high quality data is accessible to drive the development of new and improved ways of working, treatments and technologies.

3.5 Care homes should ensure preparedness for any potential outbreak by maintaining a current register of all required staff and resident data

As noted above the importance of having a current staff and resident register was critical for testing, vaccination and ultimately being able then trace positive cases to a specific care home.

All care homes in Scotland are required to maintain an up to date register of all staff and residents and this is outlined in the CI 's 'Records management good practice which states that services (except childminding) must keep and guidance on notification reporting^[16]. The challenge is keeping this up to date in a sector where turnover is high. People were dealing with the pandemic and also if all care homes has a digital record rather than a manual collection. There are no requirements to keep the CHI number of care home residents which is key to linkage with health information and was needed as explained above in the case of the pandemic to trace COVID-19 test positives to individual care homes. As noted previously in this report, not all care home staff are registered with a GP Practice, so accurate personal date on other demographics is even more important at the care home level.

A revised version of Discharges from NHS Scotland Hospitals to Care Homes^[17] (Page 81) was published in April 2021 from the data collected from March 1 – 31 May 2020 by PHS. This report recognises the need to improve the systematic recording of information on hospital records to identify when a person is either admitted from or discharged to a care home. PHS is working with NHS Boards and IT System suppliers to enable the name of the care home to be recorded on admission and discharge. This will then be submitted to PHS as part of the routine datasets. Alongside this PHS are planning training materials and reminders about why it is vital for all staff to record this information accurately.

Going forward

• The Scottish Government need national statistics which are consistent with respect to care homes. We need all national bodies to use the same definition of what constitutes a care home (i.e. that defined by the care regulator, the CI ) and we need consistent recording of care home residency in CHI and institution coding.
• The Scottish Government is currently undertaking a Care Home Data Review with partners which will appraise the quality, frequency of reporting and content of the current data landscape with a view to determining the future requirements.
• The Scottish Government will work with care homes, CI, Scottish Care and the wider sector to develop the tool so it has an improvement focus in the context of the wider data landscape.
• To supplement this learning we will work with care homes and Health and Social Care Partnerships (HSCPs) to test the use of the SHT for improvement and to align with the requirements of the national data and digital strategies.
• the Scottish Government will re-engage with the sector to showcase how the current information captured in the tool can be used by care homes for planning and early warning. In doing so consider the issue of data duplication as highlighted above.
• National local partners need to ensure that the resource invested in data collection produces data that is of sufficient quality, consistency and completeness to enable comparisons between areas over time and for local improvement also.