|This Committee meeting involved the second evidence-gathering session for phase 1 (discharge to care homes during the Covid-19 pandemic) of the Scrutiny Review of Hospital Discharge, and included contributions from representatives of South Tees Hospitals NHS Foundation Trust (STHFT) and Stockton-on-Tees Borough Council (SBC). Once again, Members were provided with several relevant links to background papers prior to this session.|
SOUTH TEES HOSPITALS NHS FOUNDATION TRUST (STHFT)
Senior representatives from STHFT gave a presentation to the Committee which focused on the following key elements:
Covid-19 Level 4 Incident (NHS Incident Levels; Incident Management)
Covid-19 Escalation (National Guidance; Estate; Testing; Personal Protective Equipment (PPE) and Staff Testing; Staff Wellbeing and Safety; Supporting Patients and Communities; Support from the Community)
Covid-19 De-escalation (Estate)
Covid-19 Recovery (Pillars of Recovery; PPE, Testing and Social Distancing; Support to the Wider Health and Care System)
Second Surge Planning
The Trust initiated a clinically-led response to the declaration of a NHS Level 4 incident on the 30th January 2020, and set-up internal working groups that mirrored the existing organisational structure. The number one priority was the protection of staff, the protection of patients, and the delivery of as much safe care as was possible. It was noted that a recent Care Quality Commission (CQC) inspection of the Trust had resulted in positive comments and feedback on its approach to the pandemic when compared to peers.
The implications of moving into a Level 4 emergency incident were relayed to the Committee, specifically the change in all Trusts having to respond to, and implement, guidance together (via NHS Command and Control) as opposed to operating with individual autonomy. National guidance often being issued on a Friday afternoon brought challenges, and STHFT quickly moved to anticipating, rather than just reacting to, changes in policy and procedures (e.g. PPE requirements).
In terms of liaising with partners, interactions with Social Care were highlighted as well as communication with the North Tees and Hartlepool NHS Foundation Trust (NTHFT) Command Centre. Throughout the pandemic, safeguarding had been prioritised and maintained, one element of which involved each patient being given 20 masks when they were discharged to a care home.
Members were taken through the timeline of key developments since the Level 4 incident was declared at the end of January 2020, a crucial part of which was the Trusts introduction of Covid-19 testing on the 12th March 2020 for all admitted patients who met the national case definition (list of symptoms), and for all inpatients upon their arrival at hospital (irrespective of the case definition) from the 6th April 2020 - this was prior to the requirement (issued on the 16th April 2020) to test patients being discharged from NHS hospitals to a care home. The Trust had quickly built-up its capacity to test on-site (though needed to purchase equipment), and was therefore well prepared for the guidance issued on the 16th April 2020 as it was already testing all inpatients. Currently, 1,500 tests can be conducted on-site daily (24-hours a day), and the Trust has also offered mutual aid to both NTHFT and County Durham and Darlington NHS Foundation Trust in relation to testing.
The impact of the initial Covid-19 surge on the Trust estate was outlined, with sites split in readiness for an anticipated huge influx of infected patients. Separating Covid and non-Covid areas in order to keep people as safe as possible involved a significant amount of work, but led to very little spread / contraction of the virus within the hospital itself. It was also emphasised to Members that the Trusts focus was not solely on delivering care to Covid-19 patients during this time, and that the ability to treat non-Covid-19 patients was only possible due to this separation of wards.
The Committee was informed that at no time did the Trust run out of PPE on-site, and that PPE was issued to staff in both hospital and community settings before the guidance around this was published. In addition, robust testing of staff was initiated, and employees who displayed Covid-19 symptoms were not allowed to come back to work until they returned a negative swab (they could not just isolate for 10 days and then return).
As previously noted, staff wellbeing and safety was a critical priority, and STHFT was the first Trust in the region to produce a Covid-19-specific staff policy. Employees on the frontline and beyond also benefitted from support provided by the psychological service, and this was key in limiting staff sickness (which was lower compared to other Trusts). Furthermore, the military experience of some of the Trusts staff greatly helped in supporting several aspects of Covid-19 planning, including the safe use of PPE.
From a recovery perspective, the Committee was notified that all Trust services had now either fully or partially resumed, and measures had been implemented to prevent the potential transmission of the virus in social areas of the estate (e.g. distancing, use of face masks). It was imperative to keep staff Covid-free so they could treat people - if not, the Trust would have let down patients.
Support provided to the wider health and care system was highlighted, including a service led by Community Matrons delivering full training, advice and a guidance package to local care homes, and the distribution of PPE to neighbouring Trusts and local care providers.
Planning for a second surge of the virus had already been undertaken by the Trust, and would again involve the re-classification of identified wards as Covid-19 areas (one ward is still operating as such). However, a further spike in cases is not anticipated to lead to the reduction of non-Covid services (as happened initially), and continuing to provide treatment to non-Covid patients, albeit in a Covid environment, would be a Trust priority.
The main issues discussed were as follows:
One Member spoke of their personal experience during a recent visit to a STHFT site and expressed concern around the level of distancing that was possible. The Trust gave assurance that all areas of care, including outpatient clinics, had been reviewed to reduce the risk of infection to non-Covid patients, and although the estate was challenged by the need to increase social distancing, STHFT had one of the lowest rates for patients contracting Covid-19 whilst going through its care (acknowledged by the CQC).
The Committee probed further around the low number of patients contracting the virus on-site and asked why this had been achieved. In response, the Trust felt it had quickly developed a gold standard by effectively splitting the hospitals in two, equipping staff with PPE, and ensuring they could use the PPE safely (a crucial requirement). As equipment was purchased and the Trusts capability grew, more robust testing became available. The Trust was compliant with the required discharge testing and had to be confident it was not sending people to care homes unknowingly infected.
Members were reassured by the systems put in place by STHFT regarding Covid-19, and commended the Trust for implementing certain measures in advance of national guidance. Moving forward, it was queried if testing capability could be further enhanced, something which the Trust confirmed it was keen on achieving, expressing a desire to get up to 2,500-3,000 tests a day if extra equipment was available - however, uncertainty around the future sourcing (equipment is in high demand nationally) and funding (support had previously been through Covid capital schemes) of equipment may inhibit this potential. Limitations on the availability of rapid tests were noted - a greater supply of these would help for urgent pathways, particularly in getting certain staff back to work.
The value of the decision to test all inpatients early on was re-iterated, and the Trust felt that if such a capability is available, it should be used (rather than wait to be told to). If this was not in place, there would have been a greater risk of placing Covid-infected patients on non-Covid wards, a situation which could have brought significant consequences.
The Committee sought further detail on the work of the Trusts Community Matrons in supporting care homes. Immediate concerns regarding the level of footfall (visitors, professionals) through care homes led to remote functions being implemented, and in early-May 2020, contact was made with 130 care homes to offer training and development sessions. Over 500 care home staff received training in PPE use, hand hygiene, swabbing patients and isolating / segregating residents. An outbreak-response (alongside Public Health colleagues) was offered, and the Community Matrons also assisted with the swabbing of residents who were displaying Covid-19 symptoms - for those who returned positive tests, support was provided to care home staff around managing the resident appropriately.
Responding to a question on the most effective innovations that had helped during the emergence and escalation of the pandemic, the Trust pointed to the provision of training and development to care homes, as well as the initiation of a named contact with care homes (which is now standard). Relationships with Local Authorities had also been reinforced (via the Trusts Command Centre and daily (including weekend) communication) as partners worked collectively to deliver the best outcomes. Nothing is more important than staff and patient safety - the latter being the first thing that is considered in any pathway (not just Covid-related).
STOCKTON-ON-TEES BOROUGH COUNCIL (SBC)
Officers from SBC gave a presentation to the Committee on the role of the Local Authority in the discharge of patients from hospital to care home during the Covid-19 pandemic, aspects of which included:
Overview (timeline of key involvement)
Enhanced Contractual Support
In addition to the timeline of key events involving the Council that took place from mid-March 2020, of vital consideration was how best to use the Rosedale Centre (a short-term residential rehabilitation and assessment centre, owned and managed by SBC) in order to support other care homes and the wider health system.
The financial support provided to local care homes was outlined, which included the passing-on of a Government infection control grant worth £2.5m. In terms of contract management / provider support, the implementation of a RAG-rating system to flag-up any issues around Covid-status, staffing, PPE stocks, capacity and critical risk areas was highlighted, information which was also shared with other key partners. Emotional support was critical during April / May 2020 and was well received by care homes, who appreciated having someone to talk to during this incredibly difficult time.
The Committee was informed of the commissioning (on behalf of the Tees Valley Clinical Commissioning Group) of two care homes for block-booked beds following hospital discharge in early-April 2020 - these care homes were chosen as they had the capacity and staffing resources, as well as offering segregation via a separate wing within the premises.
A detailed insight into the service provided at Rosedale since early-March 2020 was presented to Members, who were reminded that there are no permanent residents there, and that 95% of residents come direct from hospital. The changing of the staffing model to ensure staff remained in their designated areas and did not mix was an important element in limiting risk to both the residents and those caring for them.
The rapid development of the Integrated Single Point of Access (service based at Tithebarn) was noted - this allowed key stakeholders to be aware of patients being discharged from hospital, and, crucially, their needs. If they could not be accommodated within other care homes, Rosedale was able to step in.
From a Public Health perspective, there was close partnership-working with Public Health England colleagues (who are regionally based) in addition to collective efforts with local NHS and Social Care services and staff. Local advice and support was provided based on guidance from the regional care home group. A regional Covid care home protection / infection control checklist had been completed by all care homes in Stockton and was evaluated to understand and address emerging themes and local concerns. A programme of Covid-assurance visits to local care homes was initiated in July 2020, with updates provided to the local multi-agency operational care home group. The care home group monitors current cases / outbreaks, visits, infection prevention and control training, and compliance with NEWS (early warning system which indicates any deterioration in residents).
The main issues discussed were as follows:
The Committee expressed its gratitude to the Rosedale service, and, when considering the current Covid-19 situation, were thankful that this remained a Council asset.
In relation to the £2.5m infection control Government grant distributed to care homes, Members queried if organisations providing care in the community had been equally supported. Officers noted that 75% of the Government grant was disseminated directly to care homes, with the remaining 25% a discretionary amount - as such, a grant application process was open to both care homes and care at home providers.
Members asked about the decision to select two care homes for block-booked beds following discharge from hospital, and whether this had been an effective choice (particularly since a number of high performing care homes across the Borough do not have separate wings). Officers stated that a mixture of providers had expressed interest in offering block-booked beds, and that a decision was taken to stop allowing people into one of the selected care homes, with a replacement quickly identified.
Current levels of PPE stock were queried - there is now an alternative source available for care homes in the form of a national PPE Portal (online system). Members were also interested in the overall cost of PPE that had been distributed to care homes and domiciliary providers, something which Officers would endeavour to gather more information on following this meeting.
Officers were asked if staff numbers had to be increased at Rosedale to manage the impact of Covid-19 - it was confirmed that staff ratios were not raised, though plans were in place if this was required. Safety measures were constantly considered and, where needed, implemented in the build-up to lockdown on the 23rd March 2020, and there was no-one within Rosedale who was knowingly infected before this date. Members were also informed that a new Registered Manager for the service started today.
Thinking ahead, the Committee was keen on understanding which of the measures involving the Council had been most effective, particularly in light of the recent rise in Covid-19 cases. The ability to utilise Rosedale was of great benefit as part of a system-wide approach, and Officers confirmed that the service would be stepped-up again to take Covid-positive individuals should the need arise (Members were reminded that it is the responsibility of a Local Authority to make alternative arrangements if a care home cannot take a discharged hospital patient). In addition, the strictest infection control measures (distancing, PPE, how staff travel to work, restricting visitors) must be maintained, and a routine testing programme is crucial.
Members queried if any updates were available in relation to the CQCs Provider Collaboration Review, work which the Council had been selected to be part of (as referenced at the Committee meeting in July 2020). This rapid review, which began in the week commencing the 27th July 2020, investigated the experience of those aged over 65 who went into care homes during the pandemic, and the CQC were now in the process of preparing feedback that would be shared with the Council, the Health and Wellbeing Board, and the Adults Health and Wellbeing Partnership. Officers were aware that the support provided to care homes had been very positively recognised by the CQC, and it was noted that the regional care home group continues to operate.