Helen Whately MP
Minister of State for Care
39 Victoria Street
Dear Ms Whately,
Thank you for your letter, dated 14 May, outlining how the Government is working with local authorities to support Care Homes. We welcome the publication of the guidance on 15 May about the Coronavirus (COVID-19): care home support package and the additional funding for Bexley of £2.1m from the Infection Control Fund.
You may recall that our Leader of the Council, Councillor Teresa O’Neill OBE, our Cabinet Member for Adults’ Services, Councillor Brad Smith, and our Director of Adult Social Care and Health, Stuart Rowbotham came to your Westminster Office in early March to showcase our partnership and integrated approach with the National Health Service and wider partners. Those arrangements – integrated commissioning with the Clinical Commissioning Group and integrated provision with our Community and Mental Health NHS Trust - provided us with a very solid foundation to face the COVID challenge and throughout this crisis we have responded collectively as one. I believe that has proven immensely successful and has been the single biggest factor in ensuring we were able to avoid the most serious consequences of the pandemic.
From the start of this crisis we have fully recognised the demanding role our care home (and indeed home care) providers and their staff are being asked to play in the nation’s response to the COVID crisis. This covering letter describes how London Borough of Bexley and our system partners have been working to support the sector and our plans to further develop this through the work of our Care Home Support Task Force.
We would like to start by expressing our immense gratitude to our providers for the care and support they are providing to some of our most vulnerable residents and acknowledge the toll on the emotional health and well-being of residents, staff and managers, caused by anxiety, fear and bereavement.
From the inception of this crisis we have taken a system wide approach to discharge management from our three local acute trusts. This, together with the excellent relationships we have with our care home and home care providers, enabled us to rapidly implement the COVID-19 Hospital Discharge Service Requirements and put in place a seven-day process to enable same day hospital discharges at a very early stage.
COVID-19 has provided an unprecedented challenge to adult social care. The challenge has been significant in London due to early and rapid spread of the virus, local patterns of deprivation, high levels of air pollution and the high proportion of ethnic minority populations in most London boroughs.
Across the Capital, London local authorities responded to the challenge and our responsibilities under the Civil Contingencies Act by working together as LondonADASS and Chief Executives, alongside NHS partners to identify issues, galvanise responses and lead several pan-London initiatives. We brought our co-ordinated response together through the Strategic Co-ordination Group and joint governance with NHS London.
Using data and evidence we developed a comprehensive understanding of the London adult social care markets (home care and care homes) during the spread of COVID-19. Our commissioners used this as a key part of their daily interaction to support providers. It has underpinned and strengthened relationships with providers locally and provided information on care homes across borough boundaries, which has streamlined the work and reduced the burden on providers. Since mid-March this has supported local operational responses: prioritising active delivery of Personal Protective Equipment, ensuring appropriate staffing levels and providing Public Health infection control advice and support.
Being alert to emerging issues in the system which led to care home challenges and our early response (we started reporting care home deaths and COVID cases from 23 March) allowed action to be taken to respond in London and provided early warning nationally via the Strategic Co-ordination Group of issues that would develop across the country.
A summary of the work across London and issues for the future are captured in the London Region Appendix.
Below we summarise our Bexley system’s approach to supporting care homes. Drawing on the insights from the template completed on 26 May, we will describe what went well and our learning in relation to how we can enhance our support going forward. The feedback from our providers is invaluable to us in this respect and makes clear that while there is much to commend our system’s approach, we need to continually challenge ourselves to:
- enable easy and accessible access to testing
- ensure that no member of staff is at financial detriment as a result of being asked to self-isolate. (This does not however include the wider implications of Test, Track and Trace unless appropriate funds are made available)
- support settings to minimise the movement of staff between settings
- ensure a continuing supply of appropriate Personal Protective Equipment
- further capitalise on the opportunities presented by digital technology to support staff training and facilitate communications between relatives and residents, whilst ensuring we get the right balance between face to face and virtual clinical advice and support
In Bexley our approach to care market resilience sits in the context of our well established joint commissioning arrangements, our integrated ways of working across Adult Social Care, Public Health, Primary Care and Oxleas NHS Foundation Trust and our partnerships with our three main local acute providers.
As soon as we stepped up our local COVID response processes, daily reporting on capacity and capability of the care home and home care markets was initiated. Having initially engaged with providers to support them with their business continuity planning, we then progressed into a regular flow of daily situation reporting and two-way communications which continue to date.
Increasingly, as the crisis progressed, it became clear that our own market intelligence gained from our daily conversations with providers, pointed to the fact that far less beds were actually available than was being reported on the national platforms. This reflected our providers decisions not to accept the discharge of COVID positive patients into settings which were not able to isolate them, in particular, where dementia and other behavioural issues were a factor in safely caring for the patient and other residents.
We also took an early decision to block contract 41 beds from our existing local providers to ensure that we had the community bedded capacity we needed to implement the discharge pathway and to provide a level of financial stability for the providers. We did not however link this, or any other financial assistance, to any requirement to accept COVID positive patients. Whilst fully committed to the rapid implementation of the discharge guidance as evidenced by our early move to seven-day discharge processes, we nevertheless recognised the inherent risks of placing patients with untested COVID status in care homes and therefore took steps to differentiate pathways into care homes according to where infection control was best able to be managed. We also, jointly with our neighbours in Greenwich, developed a COVID positive step-down pathway in a temporary community setting, which very early on meant that no one who was COVID positive needed to be discharged to a care home where they could not be isolated, thereby reducing the risk of cross infection to other residents.
We gathered daily intelligence from providers on their workforce status from the outset and captured detailed information on their workforce requirements. We immediately started work on a recruitment campaign which secured a supply of candidates through the Council’s preferred provider of agency staff, with the Council taking the financial risk of retaining candidates while they were matched to vacancies. This has been an iterative process which continues now through linking with the London-wide portal. Going forward, should we have access in the local system to returning health professionals we will work with partners to prioritise deployment to areas of most need including our independent providers.
Infection Control and Prevention: Testing
Recognising the impact that the COVID status of staff was having on care home resilience we decided to target the initial scarce COVID-19 testing slots made available to Adult Social Care, to our care home and home care providers.
Our response to testing has been an exemplar of partnership working locally. Our Director of Public Health is the designated lead for testing for London Borough of Bexley. A multi-agency Testing Task and Finish Group chaired by the Director of Public Health has been set up to address the challenges in this area and continues to steer the work.
- testing pre-discharge from hospital and prioritising our allocation of testing slots to care home and domiciliary care staff was facilitated in Bexley, ahead of the change in government guidance. This was possible only through the invaluable support towards testing extended by Lewisham and Greenwich NHS Hospital Trust (Queen Elizabeth Hospital)
- guidance and flow-charts on the pathways to testing for Care Homes was developed and circulated and the Mobile Testing Unit has been set up in Bexley two days a week for the past 3 weeks. Bexley has been one of the top performers in London in terms of the number of tests done at the Mobile Testing Unit
- this facilitated the familiarisation and adoption of the national testing portal pathways when they came on-line for Care Homes, with alternative local arrangements in place for specific situations
- further work is underway to facilitate testing of asymptomatic essential workers, and on training in this area for Care Homes and other settings
- a testing mail box has been set up for Adult Social Care providers seeking support from the Adult Social Care-Public Health Response Cell system and for any enquiries: Covid.Testing@bexley.gov.uk
- there is the provision for the Director of Public Health to fast-track testing in care homes as needed.
From the template we know that providers are particularly concerned about access to testing and it is clear that we need to continue to prioritise enabling easy access to testing for residents and staff on a regular basis. We are already taking a proactive local approach to testing people with learning disabilities and mental health needs in supported living settings, recognising that these are not included in other testing schemes.
Infection Control and Prevention: Personal Protective Equipment
Having quickly recognised the urgency of provision of adequate Personal Protective Equipment for care homes:
- Personal Protective Equipment emergency supply arrangements were established in late February, moving to seven-day access to Personal Protective Equipment supplies, including delivery of Personal Protective Equipment to settings by Adult Social Care staff out of hours in response to urgent requests
- a task and finish group chaired by the Director of Public Health was established to address the challenges
- we developed our own supply chains to secure Personal Protective Equipment supply and our own approach to ordering Personal Protective Equipment
- providers were updated on Personal Protective Equipment supply issues and signposted to Personal Protective Equipment training on a daily basis initially, and now twice weekly via our provider briefings
- regular on-going contact with providers enables us to ascertain the stock levels held by each agency and to continue to secure, procure and allocate Personal Protective Equipment ensuring no organisation runs out
Infection Prevention and Control: Outbreak Management
Our Director of Public Health established a COVID-19 Public Health Response Cell in early March to directly support the Council and its partners through the pandemic. Members include a range of staff from across public health disciplines and environmental health. The cell team are also embedded in the four directorates and provide support in real time. A mail box was set-up through which all enquiries are received across the Council: C19PHResponseCell@bexley.gov.uk
- through regular communication with our care homes, we ensured that they were clear on the guidance on outbreak management, including the definition of an outbreak
- the email and out of hours telephone number of our local Public Health England health protection team was shared with our care homes, encouraging them to be vigilant and promptly identify an outbreak, and make contact with Public Health England for support
- our public health team in Bexley continues to provide focussed support on case and outbreak management to care homes. Bexley Public Health developed and offered a ‘Covid-19 in Care Homes Settings’ training to all care homes. This is currently underway and addresses a range of infection control areas including updated guidance, use of Personal Protective Equipment, testing or swabbing and prevention of outbreaks
- there is an on-going continuous process in place whereby the Adult Social Care Quality Assurance Team maintains regular contact with providers and is the first line of action in case there are any concerns. There is an escalation pathway to Public Health Response Cell for specific infection prevention and control and public health concerns
Enhanced Health in Care Homes
We have a locally commissioned service in place in Bexley which provides primary care support to all registered care homes for older people. The Clinical Commissioning Group has recently audited the practices providing the service and received assurance that the care homes feel supported by primary care. This has been reinforced by the feedback in the template. Since the inception of COVID, proactive weekly visits have become remote visits using telephone or video consultations and there is also more frequent on-line contact. All our care homes have a named clinical lead and commented positively on their accessibility via digital means. They have also been appreciative of the practical support and presence on site of our District Nurses.
Going forward our plans concentrate on:
- improving the support available for managing residents with dementia
- improved co-ordination of medication reviews
- enhancing our MDT approach with an on-going emphasis on falls prevention and speech and language therapy
- building on the learning from the crisis to shape our future support offer in partnership with providers
- accelerating the roll out of the Docobo remote monitoring system, for which we are a pathfinder site, to provide timely clinical information directly into the GP’s system for a further eight homes by July 2020
We are actively reviewing the primary care support to registered settings for people with learning disabilities and mental health needs. However, many people with learning disabilities and mental health needs live in supported living settings which are not Care Quality Commission registered and residents have their own GPs. Therefore, it is important to provide a proportionate level of support, especially to ensure infection prevention and control.
Recognising the challenging position of care homes at the frontline of the COVID-19 response at an early stage, we took action to develop and improve our existing Enhanced Health in Care Homes offer. We have stepped this up to a multi-agency Care Home Support Task Force which brings together partners from Public Health, Primary Care commissioning, Adult Social Care Quality Assurance and Safeguarding, Primary Care Networks, GP Federation, Healthwatch Bexley, Bexley Care (integrated physical and mental health services), Bexley & Greenwich Hospice, Clinical Commissioning Group Medicines Management and Quality and Safeguarding teams, Consultant Geriatrician from Queen Elizabeth Hospital, Alzheimer’s Society, Chair of Bexley Borough Based Board and care home GP, and representatives from two care home providers.
The Task Force is focused on identifying any gaps in our system wide response to care home support, especially but not exclusively in relation to COVID related needs.
The remit of the Task Force covers:
- infection control and prevention, including testing, Personal Protective Equipment, training and outbreak management
- emotional health and wellbeing and bereavement support for staff
- end of life care and advance care planning
- primary care and medication support
- admission avoidance and discharge management
- workforce support
- digital technology
Bereavement support, high quality end of life care and advance care planning are clearly an urgent priority at this tragic time. Bexley and Greenwich Hospice is leading our response by pulling together a comprehensive offer of support for staff from local voluntary partners and implementing the ECHO end of life care training across our care home community. Healthwatch Bexley will engage with our providers when appropriate to do so, to independently test our approach and feedback any further areas for improvement or development.
We are acutely aware of the financial pressures on our provider partners at this time, recognising not only the additional costs of Personal Protective Equipment, additional staffing and overtime, but also the reduced income from both the National Health Service and local authorities due, tragically, to residents passing away and less demand from new self-funding individuals. On 10 April, London Borough of Bexley wrote to providers stating that funding would be provided for; the increased use of PPE, additional staffing to support admissions into care homes (for example one-to-one during isolation period or to support a COVID positive or symptomatic resident with dementia), and flexible deployment or recruitment of staff to provide cover for absence.
We also uplifted our rates for older people residential services by 4.91% as opposed to the 3% we had anticipated prior to COVID and added an additional 1% on top of this for three months.
We continually monitor occupancy rates across our provider market and we maintain constant contact with our providers with respect to the financial risks they face. These issues are being managed on a case by case basis in line with our provider concerns protocols. The figures quoted below give an indication of funding released to date. Payments to providers of supported living services are included in the domiciliary care figures.
Support to providers that London Borough of Bexley has contracts with (to 29 May 2020)
Domiciliary Care £230,625
Residential Care £196,834
Other provision £0
Total spent so far £427,459
Support to providers that London Borough of Bexley does not have contracts with (to 29 May 2020)
Domiciliary Care £13,784
Residential Care £0
Other provision £0
Total spent so far £13,784
Notes about these figures
Note 1 - Total spent so far means funding or support has already reached providers.
Note 2 - We hold spot and block contracts with most of our in-borough care homes.
Note 3 – Figures do not include Personal Protective Equipment cost for the 12 domiciliary care providers and care homes we do not hold contracts with but supplied with Personal Protective Equipment as requested, as these are not separated in our records.
We are currently working with our local providers to ascertain whether the designation of one setting for recovery period for COVID positive residents would be a practical solution in our local market. We share a step-down unit for COVID positive patients with our neighbours in Greenwich, which meets most of our needs at the present time.
On the basis of all that is set out above I am confident in assuring you that, in Bexley, we had a strong system of support around our care homes before COVID, acted very quickly to step up our support as soon as the discharge guidance emerged, and continue to work in close partnership across the system to develop our support going forward.
Finally to reiterate, we welcome the Infection Control Funding announced on 15 May 2020. In relation to the 25% not passed directly to providers we are committed to using those funds to improve infection control and prevention in our care home and home care settings, both registered and un-registered and will be undertaking a rapid review of the evidence base for what will work best, to protect our residents and staff.
I attach our completed template for care home support planning.
London Borough of Bexley
Cc Councillor Teresa O’Neill OBE, Bexley Health and Wellbeing Board Chairman, Leader of the Council; Andrew Bland, Accountable Officer, South East London Clinical Commissioning Group.