Agenda item

Adults 65+ Residential and Nursing Care Homes - Quality Review

Presentation giving an overview of initiatives to support the care home sector and work under the Quality Strategy.


Cllr Roche, Cabinet Member for Adult Care and Health introduced the item and confirmed that Rotherham care homes, of which only two were Council homes, were now rated third best in Yorkshire.  This was positive progress although room for further improvement still existed.  Undeniably Covid-19 had had an impact on care homes in Rotherham and he stated his thanks and admiration for staff working in care homes and said that thoughts were with those who had lost a loved one or family member.





        36 Care Homes (Adults 65+) including 2 in-house

        2 market exits since 2018 Greasbrough Nursing and Residential Home (contract termination-poor quality) Clifton Meadows (business decision)

        3 market entries - Jubilee - Greasbrough, Roche Abbey - Maltby, Clifton Meadows - Clifton

        Significant bed capacity - 1849 (including in-house/temporary beds)

        483 Vacant – 26% on 22nd May 2020 (164 in general residential, 92 in general nursing, 171 in dementia residential and 56 in dementia nursing)


Current Position

        Only 48% placements funded by the Council

        22% of beds occupied by self-funding residents – still support from Council

        30% from out of borough

        50% charge a top up fee (10% in 2015/16)

        Demographic is changing, with the average age entering care increasing to 85 years (83 in 2015/16).

        The average length of stay is 2-3 years (3-4 years in 2015/16).

        Increase occupancy in Nursing type provision (90% occupancy) - people living longer - complex needs

        Market expansion in nursing beds 92 beds and 20 temporary (Covid-19)

        11% increase in vacancy factor since Covid-19


Challenges to Care Homes due to Covid-19


Initial challenges at the start of the pandemic:

- Implementation of the 3 hour discharge process from hospital

- lack of testing for staff and residents

- high rates of staff absence

- lack of Personal Protective Equipment (PPE)

- care home deaths not being captured in the national data

- digesting and responding to frequently changing guidance regarding outbreaks, PPE use and infection control – support from RMBC


Challenges now are:

- implementing the new testing regime

- high levels of voids

- limited self funder market

- longer term financial viability of care homes

- ensuring that support extends beyond older people (current national guidance limits primary action to this group) – learning disability, neuro-rehab and mental health


Additional Support due to Covid-19

        Named Council lead officer - Contract Compliance Team and Public Health Officers

        Clinical lead - GP -  Community Health Team

        Clinical Contract Quality Officer – Care Home Liaison Service (NHSRFT)

        Staff testing

        Whole home testing for staff and residents

        Supply of PPE – now improved through supply chains but some concerns re costs plus Council some stock with which able to assist providers

        Council’s website - bespoke section for providers i.e. web form to request PPE/information/support/resources

        Rotherham Skills Academy to meet their immediate recruitment and training needs for adult social care workers (to go live in two weeks)

        CQC - Emergency Support Framework - collaboration

        Training package based on Public Health England guidance for PPE, Infection Prevention and Control and Covid-19 swabbing/testing

        Sheffield University provided 35 sim enabled phones to enable video calling – residents/family

        Multi-disciplinary team clinicians/Public Health/commissioning video conferencing

        “Listening Ear” service – bereavement support

        Payment £15,000 to support additional expenditure incurred as a result of Covid-19

        £100,000 contingency fund

        Infection Control Fund – £2.3m grant for all CQC registered care homes in the borough (all age - 84 in total)


Whole Care Home Testing

        10 May 2020 - the national digital portal was launched to support all care homes to be tested by June 2020.

        The Director of Public Health, CCG Chief Nurse and the Director of Adult Care Services were tasked with supporting testing across Rotherham., as p

        Care home testing will be prioritised according to risk i.e. where there is an outbreak or where staff absence is problematic.

        All older people’s care homes across Rotherham will be included regardless of the source of their funding.

        The Director of Public Health will be referring care homes to NHS England for testing on a weekly basis as per NHS England’s directive.

        Local needs will be captured via a daily tracker.

        An evidence-based methodology informs who is prioritised for testing and support:

- size of the care home

- numbers of staff

- whether the care home is nursing or residential

- current staff sickness rates

- current bed occupancy

- current infection rates and presence of Covid 19

- testing already undertaken of residents and staff (if this is the case)

- geographical areas to take advantage of mutual aid where possible


CQC ratings

3 slides showed current ratings for Care Homes in Rotherham and an improving trend.  Contract Compliance Officers remained vigilant over the ones rated as requiring improvement, which all had action plans.  Escalation if needed would  include health partners in a mulit-disciplinary approach.


CQC data - Access to care

·       Percentage change in residential home services - Rotherham figures indicate a 5% or greater decrease in the number of people accessing residential care

·       Percentage change in nursing home services - Rotherham figures indicate a 1% or greater decrease in the number of people accessing nursing care

·       Percentage change in residential home beds - Rotherham figures indicate a 5% or greater decrease in the number of residential care beds available

·       Percentage change in nursing home beds - Rotherham figures indicate the number of nursing beds remains stable


The Care Home of the Future

        Care home market is essential where it is not appropriate or safe for a person to remain in their own home.

        Shift in market to facilitate hospital admission avoidance, discharge and flow to contribute to managing year-round pressures/demand through the provision of intermediate care, reablement and winter pressure beds from the independent sector.

        To develop more effective community multi-disciplinary working to support people to be at home for longer (or following hospital discharge), based on the philosophy of ‘Home First’

        Prevention and early intervention with a recovery model of reablement and rehabilitation for all age groups


Approach to Quality

        Healthwatch - Citizens Advice Rotherham and District

        RMBC - Public Mental Health and Emotional Wellbeing COVID 19.

        TRFT - Patient Experience Group.

        Rotherham Safeguarding Adults Board.

        Health & Wellbeing Board.

        Rotherham Advocacy Service – Absolute Advocacy: canvas independent views on health and social care in addition to advocacy

        Meet people 1:1 group sessions, surgeries, attend events, use social media and technology.


Quality Strategy

Making it Real - people with care, treatment and support needs:

        Six themes to reflect the most important elements of personalised care and support.

        ‘I statements’ that describe what good looks like from an individual perspective.

        ‘We statements’ that express what organisations should be doing to make sure people’s actual experience of care and support lives up to the I statements.


The following key themes were explored by Members following the presentation.


Stability regarding testing

The Strategic Director was the lead for the South Yorkshire Local Resilience Forum cell and confirmed that although testing remained challenging plenty of capacity for testing existed across the system, with two routes available.  Pillar 1 was via Rotherham Hospital where a pathway had been established early on for Council and provider staff and Pillar 2 via Doncaster Airport where staff could make their own referral.  Confusion existed with regard to the pathways, compounded by mobilisation of units managed by the military, such as the one at New York Stadium for a few days.  Testing and home testing kits were available for staff who had difficulties in driving to the hospital or other sites.


Testing was mainly self-testing by a throat swab, with only hospital tests undertaken by a clinician.  A high number of false tests were recorded and people had to be assisted in how to do them correctly.  An additional challenge was how the virus worked as people could still have bacteria in the back of their throat after two weeks, showing a positive test but no longer infectious.  This led to dilemmas about how safe people felt in being in a particular environment.


NHS England (NHSE) input was in regard of testing care homes one by one, which was also a challenge.  Some care homes had been proactive and this issue was prioritised weekly depending on what was happening in a care home.


Access to testing for residents and staff with the rollout to all care homes

A return for 29 May 2020 had to confirm that every care home had been offered testing and Rotherham had included mental health and learning disability even though the list was confined to older people.  It was because the belief was that anyone who lived in a care home should have access to testing.  Issues existed around capacity to consent to a test or refusal.  There was a process as a deprivation existed in doing something physically to someone who was quite poorly and potentially did not understand what was happening.  Challenges for providers with people with dementia type illnesses were around testing, social distancing, PPE, residents staying in their own room if needing to self -isolate and also decisions made for people on end of life care who may have chosen to remain in the care home rather than going to ICU for ventilation.  It remained important to have that personalised care.


Testing for older people was approximately over four weeks to cover all services.  Officers looked at what had been carried out and then prioritised care homes where people were receiving nursing care or had symptoms of dementia, and on levels of infection in the home, which were then referred to the Department of Health for the testing to be undertaken.  Several care homes had registered themselves on the on-line portal and the Council had referred around half the older people’s care homes and were monitoring when the tests were carried out and the results.  Learning disability care home testing was imminent once the go ahead was given, plus under 65s and mental health, so there would be no further delay as people were anxious about it.


Infection control

It could not be said that this had stabilised as there were a number of unknowns with regard to the virus and things emerging daily.  Work was taking place with the Director of Public Health and Community Physician and PPE training included videos of how to put on and remove PPE correctly.  Transmission was possible through staff and monitoring was in place regarding the percentage of staff who had tested positive or who were self-isolating with symptoms or because family members showed symptoms, and this would endure.


Preparedness for another spike or second wave

Assurance was sought that officers were confident that the system was geared up to deal with another wave.  There had been a lot of learning and a document had been developed for scenario testing and how things would be done differently if it started up again.  Partners were in a strong position but the caveat was that it would be different again next time; it had hit the most vulnerable and those with certain conditions and by default sadly the people in the care homes would also have changed.  The system was as prepared as possible but there were unknown aspects.


Discharge from hospital for convalescents to care homes

Learning at all levels was continuing and as always with the benefit of hindsight and acquired knowledge some things would have been done differently.  Preparatory work had been carried out for going forward due to concern about potential outbreaks.  A plan would be going to Elected Members in the coming weeks.  Planning was underway for activity whether it could be small outbreaks in care homes, communities or more widely.  There were still many unknowns and the knowledge had changed over the last few months.


The Local Authority as a system had to respond by 29 May 2020 with its care home plan, with formal feedback expected the following week.  There would be further work to do but initial feedback had been positive which officers felt should give confidence to Elected Members about what had been done with plans in place very early before many counterparts.


Multi-agency group meetings took place several times a week, including learning disability and mental health, and staff were proactively monitoring against all data to identify any trends and issues in care homes and contacting them where any issues were identified.


Pre-discharge testing at the hospital

Verification was sought on whether people were only discharged following a negative test and if there had been problems linked to this.  Learning, guidance and challenges had been almost daily and care home meetings took place seven days a week in the first two months of Covid-19.  Changes were made to the guidance part way through and when it stated that people had to be tested before discharge Rotherham Hospital enacted testing straight away.  20 beds were quickly commissioned in one care home to have a Covid-19 positive pathway for people who were unwell, with reference to the Mary Seacole initiative mentioned below.


One challenge was the length of time people may be asymptomatic, possibly for several days, which led to a changed approach on staffing, delivery and to work with care homes to get them to consider that pre-time before symptoms.  The time frame initially was one of a three week potential virus but some patients were in critical care and having ventilation for three weeks.


Nursing homes and isolation

Members questioned the degree to which nursing homes had created internal Covid-19 wards or sections to isolate residents and protect staff and other residents.  Much depended on the size and layout of the care home and some had set up specific areas, whereas in others it was self-isolation in the person’s room.  Where possible “hot and cold” sites were set up and care homes had been supported and given advice on how best to do it in their own specific environment.


On staffing there had been a degree of pragmatism and staff turnover was high, and there were issues with using agency staff.  Separate staffing teams had been set up in care homes (and in RMBC) to balance this off.  It was difficult initially when test results were not coming back fast but Rotherham Hospital was doing them quickly and becoming more rapid.


Care for people with disabilities

Assurance was given that if anyone had care and support needs, regardless of their age or impairment, they would be assessed in the same way as before the pandemic.  The reablement team were still going out and working with people, with the appropriate PPE.


Safe staffing levels in care homes

Acknowledging some of the problems with staffing, Members probed into whether regular updates on staffing levels were provided and if there had been any concerns about the safety of residents, especially in more complex cases with a higher ratio of staff to residents.


Martin Hopkins’ staff were in daily, regular contact with all the care homes and the relationships and trust were there to share relevant information both ways.  Care homes recognised that the Council needed to understand their staffing ratios and concerns in order to support them.  Each care home had a linked member from the Commissioning Team who acted as their conduit.  The team facilitated the move of a staff member from one care home with extra capacity to another that had a staffing shortage.  Officers confirmed they had not yet reached a stage of being unduly concerned about staff sickness absence levels but if the trajectory at the start of the pandemic had continued then there would have been.  Above 25% would lead to problems, and at times it had been close to this in some establishments, but higher numbers of staff were now back in the workplace, with absence levels therefore much lower.


In response to a question as to whether the staff to resident ratio had ever been out of guidance, it was pointed out that the Registered Manager in a care home was the legal entity regarding safe operation.  Data was collected on staff and the reasons for absence, on staff who had tested positive and more recently on staff who had been tested for the virus, including in RMBC care homes.  Questions would be asked of any home that had a high degree of staff absence.  All contingency plans had been reviewed and approved, modelled on staffing reductions at 25%, 30% and 50%, as in RMBC at the start of the pandemic.  A categoric yes or no could not be given but significant monitoring took place and contingency plans were enacted very early. Officers had also spoken with homes about not sharing agency staff because of the transmission risk.


Financial support for care homes

Members asked if this meant care homes would now say they were in a better financial situation, given the impact of a vacancy rate of around 26%.


The grants had been well received but as seen in the national media provider associations and some providers had made representations about longer term funding requirements and also referenced the financial climate over the last ten years.  Fee uplifts has been provided in Rotherham and officers worked within the budget available to support the establishment but divergent views on the level of funding were expected.  In terms of Government pandemic monies, the Council had sought to support care homes, not only in a direct non-cashable way, but also through direct contact and support from staff and health colleagues.  Support from the named GP for each care home had been appreciated by the sector.  Further potential funding was not known at this stage.


Care home entry

As the trend showed later entry into care homes and shorter stays, the question was asked if this indicated successfully supporting people at home for longer.  It was confirmed that part of the overall plan for Adult Care had been to reduce the number of care home residents by supporting people to live more independently at home for longer and overall numbers had fallen from 1,200 to around 800 in the last few years.  Sadly, some of the change was attributable to Covid-19.


Surprisingly, across Yorkshire and Humber expected demand for social care support had been lower than anticipated until a slight recent increase.  In part this was because family members who had been furloughed had been in a position to provide support at home where unable to do so before, including for domiciliary care, but that was beginning to change.  Uncertainty existed regarding the trend and it would be monitored but Rotherham was no different to elsewhere in South Yorkshire.


In terms of 30% of placements being out of borough and whether this had fluctuated with the crisis, this was data from March when the update had been due originally.  It had not really been collected recently with the focus elsewhere but the assumption was that the position would have shifted.


Government guidance

Members recognised that this presented a major challenge as it was announced at night and expected to be implemented from the next day with health and care partners having no prior knowledge of what would be announced.  PPE guidance had been very complicated from the start in terms of understanding when to use and when not to use PPE.  Some of this had been driven by distribution lines and some by still developing an understanding of transmission rates.  Staff had not used repellent goggles and visors before.


Audit trail

Assurance was sought that the Council had clear timelines and data to marry up activity with Government guidance as issued or changed.  Care homes had action plans and logs for older people 65+, learning disability and mental health.  Every time a change was made in our approach, a clear audit trail of everything done was in place to give assurance to ourselves, Members and anyone else who might ask and to show the decision-making on changes to the approaches.  Cllr Roche verified the robust and thorough audit trail and detailed information provided with sitrep and surveillance data and confirmed that everything was formally minuted to provide additional assurance on this point.


Probing further beyond RMBC data, Members asked about data on what others did and where and when the problems/issues had occurred.  As it sounded very reactive to Government announcements, a follow up point was whether there had been scope to do what we thought was right for our local circumstances.  Assurance was given that what was done was from a Rotherham perspective and with staff having good knowledge of our local provider market this facilitated knowing where to deploy extra resource.  It was a question of interpretation of the guidance and was very evidence based.  Nursing staff dedicated to care homes had been involved in all the training and the continuity and local deployment was integral to how this was managed and what was right for an individual care home.


Care home deaths

Officers were asked if they had data on deaths in local care homes over the last three months and how this compared with the number of expected deaths for the period.  Originally figures reported nationally were only for hospital deaths from Covid-19 but that had changed to include all deaths.  Sadly, people had potentially died from Covid-19 before much was known about it.  This information was part of the Public Health data surveillance captured through the local and the South Yorkshire surveillance cells.  An update could be provided at the next Health Select meeting when the Director of Public Health would be able to attend and provide a full picture and set the context of collecting different data at different times.


Community confidence

Members were concerned with regard to the challenge of instilling confidence in people if they had to go in a care home and felt fearful.  This was acknowledged as a concern for Adult Social Care, whether for respite or long term support.  A South Yorkshire-wide communications plan for care homes was under development as it was the same for all local authorities to help people understand that care homes were as safe as they could make them.  PPE supplies were better now and wearing masks had become more of the norm for staff.  Another concern was in the case of carer breakdown.


Care Home of the future and integration of health and social care

Attention was drawn to the Mary Seacole initiative for hospitals for rehabilitation and recovery which echoed the past in terms of convalescent hospitals and could be similar to a small community hospital.  Recovery time from Covid-19 was longer than anticipated but it was not yet clear if there would be one in South Yorkshire or Rotherham.  People did recover better at home in their own environment and it was the intention that people returned home once they recovered.


A video from NHSE through the Care Home group showed the recovery of people from Covid-19.  It was a good message but one flaw to report back was that people giving care from less than 2 metres distance were not wearing PPE.


Members were positive about the approach to quality but commented that it was dependent upon people’s willingness to give their opinions.  This prompted a further question on capturing the service user voice in care homes, including in the care home of the future, as this had been an issue explored at the previous care home update.


Business as usual was not taking place and no Care Quality Commission (CQC) inspections were being undertaken.  As the regulator, the CQC was the body to test out the voice of the user and knew what they would expect to see and hear in care homes, with a framework for how would undertake their inspection regime.  Martin Hopkins’ team would normally also go out and talk to people about how it feels and moving forward would have to look at how that was captured in a different way.  Multi-disciplinary input provided a good sense from residents of what was happening and staff learning too was a part.


The new Healthwatch contract commenced from 1 April 2020 at what was obviously a difficult time but had done well using digital resources to make connections with people.  More could be done to develop capturing the resident voice and feeding back on quality and the new contract would help to strengthen what had been happening before.


Under the Quality Matters agenda the “I/We” statements would inform what good looked like and the new contract for advocacy would support people to be heard, including those living in care homes.  Surgeries and one-to-one meetings would take place, using the voluntary and community sector to have that contact.  For issues in particular care homes letters had gone out and people have been reassured that the Council retained an oversight during this period of Covid-19 lockdown.  Officers were asking care homes about their preparations for when lockdown was lifted and measures to recover and restore so relatives would be able to visit.



Having touched on CQC earlier, more detail was requested regarding what was happening with the CQC and if extra assurance was needed from our side.  Officers had met with Julia Gordon, CQC inspection manager for the area and discussed any pertinent issues in relation to any individual care home and the sitrep data.  The Contract Compliance team also had good links with the CQC inspectors.  CQC were putting in place an emergency support framework for contact with care homes and would undertake a mini assessment of the situation which Contract Compliance officers could view and any issues could be dealt with through this link.  Dialogue took place with colleagues in district nursing and the hospice services who were regularly going into care homes, so a good discussion network was in place providing oversight.


Quality Board

The Chair asked how the work of the Quality Board been progressing, especially Quality Matters and the Leadership Academy, prior to the pandemic.  The Quality Board membership comprised a range of partners and was a good forum for sharing intelligence.  Initial discussion had focused more at a micro level around individual establishments but was moving forward towards becoming  more strategic.  The aspirations for implementing Quality Matters remained but it was in its infancy and had not progressed as quickly due to the pandemic.


Quality Matters was more of a national or regional approach with CQC Skills for Care and Think Local Act Personal (TLAP).  Common data sets were being looked at for monitoring across services and meeting the reporting requirements of the various bodies.  Ideas for improvements in monitoring quality had been put forward, which included leadership.  Data capture and collation systems had also been explored, including systems available commercially.  The advocacy service was involved in monitoring quality and improved relationships had developed across health partners in terms of their work on enhanced health in care homes.


Registered Manager turnover

Members highlighted the importance of having good managers in post in these difficult times and inquired if the longstanding issue of Registered Manager turnover had been addressed.  The Leadership Academy/Registered Managers had been discussed with the Learning and Development team and would be picked up when things were stepped down in relation to Covid-19.


Intermediate care/reablement

As this was a key element in service transformation the question was raised as to whether it would be able to progress alongside the work in care homes with what was happening regarding staffing and capacity with Covid-19.  The work had been paused for now with staff doing different things but later in June or in July the integrated place plan would be reviewed and priorities redefined for the remainder of this year and ones to carry forward to next, so a further update could follow in August.


Officers were thanked for their good, informative presentation, comprehensive answers and attendance at the virtual meeting.




1)    To note the information provided in the presentation.


2)    To receive a detailed presentation of the surveillance data at a future meeting.


3)    To have a further update, to include intermediate care and reablement, after August.


4)    That HSC record its thanks formally to staff for their work and dedication during the Covid-19 pandemic.


Supporting documents: