This article contains original stories and statistics on care homes in the second wave of Covid-19, as well as a review of the guidelines given on government and advisory websites. MS Guardio supplies a wide range of products for health & safety protection in care homes across the country, and are currently producing a range of advisory articles on the development of care.

To navigate our compilation of Covid-19 guidance for care homes in the second wave please use the links below:

1. Monitoring for deconditioning and deterioration
2. Wandering residents 
3. Visitors
4. PPE
5. Agency workers and sick pay
6. Staff mental health
7. Testing
8. At-risk workers
9. Zoning and cohorting

The UK’s health secretary, Matt Hancock, claims that the government ‘threw a protective ring’ around care homes from the start of the 2020 pandemic – but care homes all over the country report feeling abandoned. Stuart Miller, director of the Department of Health and Social Care, warned on 11 September that cases of coronavirus in care homes were rising again; the second wave had begun.

Inside care homes, the virus has affected residents, care workers and managers in ways that extend far beyond the parameters of the illness itself. Residents have been distressed by the implementation of new rules that they do not fully understand. This is a worldwide issue: Ari Hyman, administrator of the Montefiore Home in Beachwood, Ohio, tells a story that is difficult to hear. Patients with dementia cannot remember that the pandemic exists. Mornings at his care home usually see residents in the Alzheimer’s ward congregate centrally, a pattern that is good for their wellbeing under normal circumstances. But now, those mornings involve care workers having to separate groups of elderly residents, friends who are used to this morning ritual and who do not understand why it cannot continue. 

Hyman says that although they went from room to room when the pandemic began, explaining the new rules that would have to be applied, some of the residents could not understand or hold this in their memories. Face masks are mandatory in The Montefiore Home, but patients with Alzheimers grow frustrated with the masks and rip them off. Being told why they have to wear them involves being introduced to the idea of a deadly disease yet again – some may have to go through this experience multiple times a day.

Elderly hospital patients were offloaded into care homes to make way for Covid-19 patients

Data from the Office for National Statistic shows that only 19% of care homes were closed to new admissions from May to June. Elderly patients, who had until then been living in hospital wards highly likely to have been exposed to COVID-19, wore the new virus home like a new set of pearls.

Speaking to Eileen Chubb, director of Compassion in Care, it seems as though not much has changed since then. The Compassion in Care hotline deals with care workers who wish to report malpractice at their care homes. They have received calls from care workers concerned about the fact that their care homes are still admitting patients discharged from hospitals.

This time around, the government has said in its winter plan that hospitals discharging patients into care homes will test those patients for COVID-19 first. Care homes will still have the option to admit patients who have tested positive, but at least this time they will know. After a higher death toll than is normal – occupancy rates are down by about 10% – some care homes may need deals brokered with hospitals. Contracts with hospitals can be highly lucrative. Care homes may attempt ill-advisedly to accept patients with coronavirus and to have them isolate within the care home.

But care homes are built as homes, not as hospitals; they often do not have the physical infrastructure for effective quarantine zones, and this is a massive risk to take. Care homes that have learned from the first wave do not allow financial pressure to weigh in on their decisions in this regard. Care home insurers, worried about the hospital discharge scandal, may even refuse to give out insurance or significantly raise premiums if hospital patients are indeed funnelled into care homes.

Chubb says that elderly patients are escorted almost forcibly off hospital wards in order to make space for new patients. She says that the government’s ageist approach to elderly people has singled them out for different treatment, and shifts them out of hospital as though they deserve the beds less than others.

15,000 beds had to be free by March 27, the health department told hospital chiefs, only nine days before that date. In the rush to free up beds, frail and elderly people were discharged at breakneck speed. The mass discharges, along with new pop-up Nightingale hospitals, opened up 33,000 NHS beds, but may have caused irreparable damage to elderly lives. Once moved into a hospital-allocated care home, it is often difficult to move an elderly person to another, preferred choice. Hospital discharges may leave many elderly people in permanent living situations they did not choose, far from family and support.

Carers try to raise the alarm

 Care workers have tried to raise the alarm on issues faced by care homes in the second wave of Covid-19 and the ways in which safety measures are not followed, but their pleas are ignored by all but one woman: Eileen Chubb.  In fact, their whistleblowing has been rewarded with job losses. Compassion in Care’s Covid Crisis Special Report notes that 71% of care workers who raised concerns over malpractice have faced harassment and adverse treatment since.

Chubb tells us that some care homes are so desperate to limit the damage done to their reputations they don’t notify all care staff when a resident is exhibiting symptoms of Covid-19. Her hotline has received calls from carers who have attended to Covid-positive residents without appropriate PPE.

Care workers have been among the hardest impacted by the pandemic

In the United States, admitting residents into care homes from hospitals looks a bit different. Facilities such as the Montefiore Home are large and purpose-built, with 294 beds and two separate wards for long-term residents and post-hospital short-term residents. This may mean that that American care homes in the second wave may be properly equipped to receive elderly hospital patients into their facilities – and can ensure full separation from the rest of their population.

Some care institutions in the United Kingdom are currently advertising vacancies in their homes, and ask incoming residents to isolate at home. Asking for meaningful isolation from an elderly person who needs the support of a care home may, however, be wilfully ignorant. Those who wish to move to a care home have most likely needed at-home care or assistance from family members for some while, and isolation would leave them without such assistance. These care institutions note that any care workers needed during an isolation period should wear a mask, gloves and an apron – but assistance with toilet trips and bath times or round-the-clock care may well negate the effectiveness of such equipment. 

What care homes in the second wave can do: Residents

Hospital discharges amid a UK bed shortage

Care homes will face a new round of decision-making as the country heads into the second wave of coronavirus. Pre-planning for an outbreak is integral to minimising an outbreak. Step-by-step plans, short written briefs for agency staff and training drills may all help your institution prepare well. We’ll run through what those plans may want to contain below.

An ageing population has already spelled out difficulty for the care sector, with higher numbers of beds needed to cater for a growing segment of society needing round-the-clock care. The coronavirus pandemic has only added to that strain, leading Julian Evans, head of healthcare at consulting firm Knight Frank, to echo a widespread sentiment: the UK healthcare industry needs government investment. Overall bed numbers have increased somewhat with new care homes being built, but the newly-built beds are not keeping apace with the number needed. 

Covid-19 will only worsen the bed-space crisis. Many anticipate a number of care homes to shut down after irreparable damage to their reputations, as well as after altered care requirements as a result of the pandemic. With more care homes closing or struggling to remain viable and make a profit, there may not be enough beds to accommodate the elderly. Each home will need to decide its policy on residents needing to return to the care home after a hospital stay, as well as on new admissions and hospital discharges. Patients discharged from hospital will be tested 48 hours before their transfer, and government guidelines set out that any admissions from hospital should isolate in their own room for 14 days. No care home will be forced to accept an existing or new resident if they feel they do not have the infrastructure to cope safely with the coronavirus threat. A £1.3 billion fund is available to local authorities for housing patients that care homes cannot facilitate.

Regular testing and monitoring residents have been key to preventing outbreaks in care homes

To account for the unpredictability of symptoms, a regular testing schedule should be observed, in addition to a schedule for monitoring residents’ general health. The Montefiore Home monitors their residents three times a day, checking for the usual symptoms and other signs of deterioration in order to catch outbreaks early. When taking vital signs, staff may find it helpful to use the RESTORE2 tool which can help alert them to soft signs of deterioration.

Symptoms to screen for include the well-known symptoms – temperature, cough, shortness of breath and a drop in O2 saturation – as well as multiple other signs. Care workers with longstanding relationships with their residents can often pick up on these and know when they indicate something out of the ordinary: sore throat, loss of sense of taste or smell, sniffing, muscular/joint pain, headaches, nausea, diarrhoea, worsening confusion, loss of appetite, conjunctivitis, skin rash and drowsiness.

As well as monitoring for physical symptoms, staff should also be encouraged to take note of residents’ mental wellbeing during these checks. Discussing the effect the pandemic might be having on them can help residents feel cheered and supported. Speaking to Watermoor House, an independent care home in Cirencaster, we learn that they hired a new chef just before the crisis began – to cheer the residents with higher-quality food. It’s worked; many residents have put on weight. The smell of vinegar in the evenings announces a home favourite: traditional fish and chip dinners entice many out of their rooms.

Advance care planning has also become more important now. Rather than waiting for a resident to fall ill with Covid-19 and then having to juggle planning their care alongside physically providing them with that care, care homes should create individual care plans for each resident specific to Covid-19. If an outbreak does occur, and a resident is seriously affected, the care plan can kick into action without the lag of consulting relatives. These advance care plans should be formatted in a way that is readily accessible – for example, keeping a paper copy in the care home as well as an electronic file that can be shared between institutions. 

Loss of physical conditioning is another real threat to residents’ wellbeing. Deprived of their usual exercise, walks around the care home and trips outside, residents may experience reduced mobility – even some falls, as well as becoming confused, losing their appetite or withdrawing. These could be atypical symptoms of Covid-19, but once that’s ruled out it is likely to be a result of physical deconditioning. 

This can be prevented if a care home keeps up a regular schedule of exercise activities for residents. Socially-distanced exercise classes may be a good idea, or more informal methods for getting them moving. The Care England website contains a pdf with useful exercising resources, as well as singing, virtual museums and even a safari experience streamed live from South Africa.

Seventy-nine percent of care homes are reporting that their residents with dementia are experiencing mental deterioration as result of the lack of social interaction. In April, ‘unexplained excess’ deaths from dementia were 83% higher than usual. The Alzheimer’s Society attributes this to cognitive deterioration as a result of isolation: family can no longer visit. This may be for an important reason, but for people with dementia it feels as though they have been abandoned with no explanation.

Designating ‘explore’ areas can help meet the needs of residents who walk with purpose

Asking a resident why they want to walk may reveal pain, a need for exercise, that they’re re-living an old role, or some other need. Thinking about the person and their life history may reveal what purpose they are trying to serve by walking.

If the need remains unmet, it may be possible to allow the resident to play games in a corridor when no one is around – closing all other doors and wiping down the surfaces afterwards – or to walk around an empty garden. Some residents may be able to tolerate wearing PPE, expanding the places they can walk. The British Geriatrics Society recommends designating safe ‘explore’ areas within the care home’s zones for residents such as these to walk around in.

Losing company and community

Losing visitors has been a blow to care homes, particularly those that deal with high proportions of residents with dementia. Dexter Manley* works at a London care home as Director of Operations. He tells us how his care home has struggled to replace face-to-face interactions: residents with dementia, he says, don’t understand that they’re seeing a loved one when they’re presented with a screen. They are less able to translate the picture to reality; they touch the screen as though it’s a toy. Patients with dementia may not be able to remember the names and backgrounds for their visitors – but they will notice the absence of visits, and feel deserted.

Visitors are allowed at Dexter’s care home now, after having to complete rigorous health questionnaires, but many residents don’t have anyone to visit them. Relatives who are too nervous to leave their homes, who are unwell, or who live in areas of the country that are under lockdown, cannot provide the social interaction and physical contact necessary to prevent a condition like Alzheimer’s from declining. Stories of care home residents no longer recognising their loved ones after a long isolation are spread thickly across the country.

Dexter mentions that his care home has implemented a system of ‘visiting’ for those who haven’t had real visitors for a while. The system involves staff workers being assigned to different residents and sitting down with them for twenty minutes in ‘visit’ style – having a cup of tea, chatting, or even sitting in silence.

Any visits that are allowed have to be extremely tightly scheduled. Dexter’s home houses up to 180 people; to get through 180 families during visiting hours would take around a month, or more.

Tight schedules are very necessary, but relatives travelling to the care home from other cities may lose their slot if there’s traffic. Slots are few and far between, with extra time needed for the health questionnaire, being briefed and putting on PPE.

Ari Hyman’s Ohio care home has been one of the more successful care institutions when it comes to keeping up residents’ morale. This is partly from being part of an active, close-knit community. High school students have donated tablets for the residents to use, Girl Scouts dropped off cases of cookies, and a local animal sanctuary brought two horses to their courtyard to be petted and admired by all. An influx of cards and letters has led to a member of staff being designated to print and distribute them, as well as a ‘communication concierge’ set up for relatives to schedule video calls. 

Not all care homes, however, can tap into a local infrastructure so ready to support their elderly. Homes in rural areas, or within towns that have ageing populations, may have suffered from a lack of community support.

Social media platform Tik Tok is one community that any care home can access. A care home in Kettering has used the app’s popular dance routines to engage their residents and has built a massive online following. Videos of Westhill Park residents dancing to tunes like ‘Funky Town’ have gone viral, and the care home’s page has garnered 2.7 million likes. Residents look forward to learning the dances and interacting with this tangible online community they’ve become part of. Other care homes, such as Wellburn House in County Durham, have had similar successes – Tik Tok viewers clearly have an appetite for this kind of thing.

Video call technology has kept care home residents connected to their families

A ‘cuddle curtain’ hugging booth, made by Antony Cauvin from Stratford-upon-Avon with only a shower curtain and a pair of ordinary rubber gloves, has gone viral. Many have since copied his design. The hugging booth allows people to hug their elderly relatives without touching or breathing on them. Care homes in the second wave, having exhausted Zoom’s resources, may want to explore using innovations like these.  ‘Disinfecting booths’ at entrances are another innovation that can be experimented with.

Care homes that do choose to allow visitors to enter should create a fully comprehensive visitor infection control policy, including PPE training on top of the PPE supplies themselves. Zoning, or demarcating, visitors’ areas has been reported as successful where implemented. All areas that visitors spend time in, such as entryways and rooms for donning and disposing of PPE, should be marked off, regulated and sanitised. This can prevent the transfer of the virus between different zones within the care home. 

Zones are part of a policy that will be explored later in this article, and should be under continual review. They should be implemented in conjunction with careful consideration of where staff and supplies (including waste) are rotated or transported throughout the home. 

Agency workers and the fiasco of testing

Dexter Manley remembers listening to the evening news along with his fellow care workers, hearing the prime minister or one of his colleagues making announcements at press conferences, and laughing in disbelief. Nothing that they heard on the news was implemented in their day-to-day experience. He says they all felt a tremendous ‘disconnect’. Testing was promised but not implemented, PPE was supposedly widely available but they hadn’t seen any of it.

The Guardian revealed that 90% of Covid-19 tests administered in care homes during the month of September took longer than 48 hours to yield results. More than half of those tests took over three days to come back. The delays, well over the 48-hour deadline promised by government, compromised the effectiveness of testing and the ability of staff to isolate appropriately.  The position of care homes in the second wave looks alarming.

The situation in America is not much better. Ohio’s Montefiore Home did not receive PPE supplies from the state for over two months after the pandemic began. When the Federal Emergency Management Agency did finally ship them some protective gear, it was a paltry amount – far from anything able to protect their large numbers of staff. They have had to survive on PPE sourced from private contacts.

The only care homes able to weather the storm of PPE mess-ups were the ones that saw the threat coming. Watermoor House displayed an unusual amount of forethought when they bought large stocks of PPE as early as February. Helen Wallace, business manager at the care home, tells us that they kept tabs on the virus from extremely early on, and predicted that what was happening in other countries would in due course happen in the UK. This sounds logical with the benefit of hindsight, but many businesses and care homes did not assume the same, despite the virus’s creeping progress across the globe.

Another obvious threat to care homes are agency workers, circulated as they are between different care homes. Dexter’s London care home has made sure to only hire agency workers who could afford to work for them exclusively. Watermoor House behaved similarly, paying a transfer fee so that agency staff only worked in their home. But even permanent carers’ daily commutes have caused consternation among care home managers.  To avoid infections picked up on long commutes, one care home in the outskirts of Lyon locked down for 47 days and nights, housing all their staff within the home itself, on mattresses on the floor. It worked – the Vilanova home managed to stay infection-free, while 9000 deaths were recorded in other care homes in France.

Some care workers have been forced to re-use PPE taken from bins

The 2002 SARS outbreak taught care homes invaluable lessons on virus control. One of these lessons was that staff developed a false sense of security when working away from SARS-infected patients, and when wearing PPE. It is important to reinforce that PPE is not a magical barrier, and that appropriate caution must always be taken.

Staff need training and also retraining at appropriate intervals to ensure continued best practice when updates to PPE guidance are released to care homes in the second wave. This illustrated guide produced by the government should be distributed in strategic positions throughout the care home. A more detailed explanation for the varying levels of PPE required in different care situations can be found here. Staff members should familiarise themselves with it to understand the real effect that PPE can have – otherwise the rabbit warren of rules around the topic can be highly confusing. It is important to note, however, that these guides do not replace the standard infection prevention precautions outlined by the National Institute for Health and Care Excellence (NICE), which should still be followed as usual. 

Employers should ensure that workers undergo both fit and seal tests for their masks – masks are not one size fits all; even things like dental work can affect how well they fit. If a mask is not fully sealed it will not protect against the coronavirus.

The regulations around PPE are complex and difficult to track, so it may be worthwhile to set up a system of checks or reviews each week. For example – the face mask used during aerosol-generating procedures must be different to the usual fluid-repellant masks, and should be models that do not include an exhalation valve. A designated staff member can be responsible for this, which would increase carer engagement with rules that are constantly changing.

Care workers’ mental health must be provided for

Watermoor House, for example, has introduced emotional mapping. They give one-on-one sessions to their carers and run regular checks on their mental wellbeing. This small, independent care home in the heart of the Cotswolds houses only 38 residents, has a low staff turnover rate and its carers live within 20 minutes of the home. The family feel that this produces, according to Helen, has helped staff and residents pull together and feel more positive throughout the crisis.

Managers may consider implementing some of the following in their care homes in the second wave: support groups, mental health days, regular breaks, check-ins, and relaxation rooms. Bonding sessions to help the care home feel more like a home for staff and residents may also be a good idea (webinars are available in support of the mental  health social care sector).

One initiative that worked for the Montefiore Home was to bring in more staff workers to support their permanent staff. This comes with its own difficulties – carers from agencies may transfer the virus from one home to another – but as far as staff morale goes, it has had positive effects. Their carers feel well supported to do their job in circumstances that require more work – particularly sanitation. Financial incentives were also put in place to keep staffers loyal and make them feel counter the effects of an uncertain job market and littler financial security.

Measures like these may be more difficult in the UK care market, however, which had already been suffering  in recent years. A shortage of qualified nurses and higher building costs, according to a Knight Frank report, was already making its presence felt before the pandemic arrived. Care homes in the second wave will find it difficult to hire extra staff.

Hyman also makes the point that uncertainty took a huge toll on the mental health of his carers. This passed, however, when a clear plan was given and carers saw its results. When 200 patients did not fall ill overnight, as Hyman puts it, they felt reassured that their actions could have a concrete impact on warding off the virus and keeping both themselves and the residents  safe. The virus was no longer a mythological beast, but reduced to bullet points on a page.

BAME care workers have to be carefully risk-assessed

Coronavirus reform: the future of care

The future of the care industry is likely to be heavily impacted by the virus. During our conversations, Dexter highlighted the stress his industry is under. In the course of his career he can remember four or five royal commissions being set up to examine the state of the care sector. Each government made grand pronouncements and resolutions, but nothing has been done. 

Dexter, director of operations at a London care home, sees a gaping need to reform the way that care is paid for – ‘the NHS pays for an 80-year-old’s broken leg’, he says, ‘but they don’t pay for their dementia care’. But government funding to local authorities is at risk of diminishing in the next few years, as the government seeks to pay off its coronavirus debt and as higher taxes mean that fewer people will be able to afford to pay for their parents’ care. The care home trading performance index shows that local authorities provide 44% of care homes’ income, and private pay makes up the other 45%. This model is may not be sustainable..

The impact of coronavirus on care homes may change key aspects of the industry. Knight Frank predicts that telemedicine may become a larger part of the operation of care homes, in order to decrease the number of physical ambulance conveyances and hospital admissions. The advance towards telemedicine, already underway, has been accelerated during the pandemic. The Wessex Academic Health Science Network, for instance, has sped up its plans to roll out a telemedicine programme in Mid and North Hampshire as a result of Covid-19, and others will not take long to follow. Technology is also likely to play an increased role in future care homes, after digital planning systems and video-call technology were so vital to care homes this year.

Care homes under construction may be reviewing their plans at this very moment. Research conducted by the National Care Forum showed how difficult it was to contain infection in collective living environments. New care home builds may take this into account, and structure their buildings to work around future outbreaks.

The coronavirus pandemic has highlighted the fragile relationship between government and the care industry. It is clear that this relationship must be strengthened, and despite the privatisation of the care sector, the government must have a more involved role. When crises like this occur, the government must be able to build on an existing working relationship with care homes. At the moment, a sea of competing bodies which all aim to advise on health and social care has created a detachment between government and care. 

As Helen from Watermoor House complained, guidance to care homes in the second wave is being issued from multiple overlapping organisations, none of which appear to have consulted each other. Care home managers are having to ‘sift’ through vast quantities of guidance alone.

The old structure of what was considered good practice in care homes has been overwhelmed by the rapidly changing tide of events. Care homes have lost their anchors; codes of conduct built over decades but rendered inadequate by the pandemic. The whole concept of good practice will be rethought over the next few years in light of infection control principles. Care home managers should not be left to navigate these uncertain waters alone, nor to bear all responsibility for failure themselves.

*Name has been changed