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

4. Early Warning Systems

The RCA report cited a lag in turnaround time for testing results as being a factor in delay of a care home declaring an outbreak. This also impinged on a managers ability to identify and react quickly in order to put in place additional control measures.

Early warning indicators require to be sensitive to a number of factors including; staffing, sickness absence, increased testing initiatives test kit availability and community prevalence.

A knowledge of broader COVID-19 symptoms among care home staff was acknowledged as key within the report as was the added degree if suspicion that comes with that. The report noted an example of one failure to swiftly introduce control measures following one symptomatic resident only being tested on their admittance to hospital and that communication of findings were not reported back to the care home by the NHS.

An outbreak definition requires identification of two or more linked cases and thus a single case may not trigger outbreak precautions, but this potential 'early warning' system needs to be activated at the level of individual hospital teams communicating with care homes, whether the individual is being admitted or discharged. In practice, the notification is likely to occur if the resident is being discharged, however it has the potential to be overlooked when residents are being admitted/remaining as inpatients due to their illness presentation as not all clinical staff know that there is no central notification/alerting system and the importance of sharing this information themselves.^[18]

In the second wave of the pandemic NHS boards were identifying outbreaks earlier and dealing with them more swiftly and responsively. However it was highlighted that there was delays between the first known or confirmed cases and the declaration of an outbreak in the safety huddle data. There was a variety of data issues throughout the system which not only contributes to delays in timeous action being taken in care homes but highlights the importance of early warning systems.

The CI gathered information on suspected and confirmed cases notified to them and shared this daily with local public health teams. They developed support for services who had a suspected or confirmed outbreak by direct contact with the service to ensure the manager had put in place the current and up to date guidance. Due to level recognised level of risk with COVID the CI required notification of one confirmed or suspected case and not two as is the definition of HPS.

Recommendations:

4.1 TURAS, and supporting processes for its use in the HSCP and care homes, should continue to be further developed to ensure it can be used as effectively as possible as an early warning systems.

Progress

As indicated in the sections above work is ongoing to streamline data across Health Boards/ Health and Social Care Partnerships (HSCPs) to ensure that cases of COVID-19 (or other pathogens) can be picked up swiftly and acted upon. The use of the SHT as a reporting mechanism for outbreaks needs to be reviewed in line with the work PHS has carried out on HP zone.

4.2 Care homes should be supported to use the TURAS data for local improvement

Progress

As outlined in the section above, work will be taken forward with care homes and the wider sector to explore the use of the tool for improvement. The TURAS platform has also enormous potential for training and education more generally and allowing material to be accessible to care home staff.

4.3 A further detailed review of staffing rosters and workforce capacity should be considered based on the findings from the TURAS indicator data, it may be helpful for care home oversight groups to work collectively with care homes in the use of workforce tools to enable system level planning and mutual support

Progress

The Health and Care (Staffing) (Scotland) Act 2019 will be enacted in April 2024. The CI 's Safe Staffing Programme (SSP) was commissioned by Scottish Government in preparation for this.

In 2023, the CI will make recommendations to Scottish Government about whether there is a need to develop a staffing method particularly (but not exclusively) for care homes for older people. The SSP will also review how workforce data is collated and analysed and make recommendations for change.

In addition, the CI introduced a staffing Risk Assessment Document (RAD) which enabled services to inform them when staffing levels were critical or reach crisis point. These were shared with oversight teams to enable supports to be put in place in care homes to ensure safe staffing levels. This has now been removed but a new notification around staffing across social care has been introduced which gathers information on vacancies in care services and data is shared with Scottish Government and informs Scottish Government Gold.

Going forward

• The Scottish Government will work with national bodies to understand the appropriate role for TURAS (SHT) as a mechanism for reporting COVID-19 ( or other outbreaks).
• The Scottish Government also need to clear who is primarily responsible for reviewing/analysing the data on outbreaks and the flow of data from SHT to those who need to see/act upon that information.