The Joint Committee received information on the Overview of the Regional Response to COVID 19 focussed on Care Homes, which was detailed in the circulated report collated by Jack Straw, Independent Chair of the Health and Social Care Group, on behalf of the Extraordinary Regional Partnership Board.
An introduction was provided by Andrew Jarrett, Director of Social Services, Health and Housing, which included context and clarification on the different areas of responsibility of the component parts of the Regional Partnership Board. It was highlighted that the virus had a profound impact on the care homes, residents and staff across the UK; 46 residents of Neath Port Talbot care homes had died, including one member of staff.
Members were informed that now that the first surge had passed, the service area across the Swansea Bay Region, wanted to make assurances that they had done what was needed and required of them in terms of safeguarding care homes and that they would be able to consider lessons learned which would help if a second surge was to emerge.
Very early on during the pandemic, it was noted that an emergency response infrastructure was set up to report to a gold command group, which Jack Straw was commissioned to Chair; the emergency response infrastructure was also made up of the two Directors of Social Services and the Executive Director of the Health Board. It was explained that there were many groups who reported to the gold group including a silver group, which looked at the operational details of the response across the health and social care sector. It was added that the gold command group reported to the Extraordinary Regional Partnership Board, which was set up as a result of COVID 19.
Members were informed that the Regional Partnership Board was made up of three statutory partners, the Health Board, Swansea Council and Neath Port Talbot Council, who were commissioned to deliver the statutory service on an individual basis. It was noted that at the beginning of the pandemic, the Extraordinary Regional Partnership Board was set up with the three statutory partners, which meant that the general Regional Partnership Board, made up of representatives from the third sector, carers, patients, citizens and social landlords, did not take part in the decision making process as it was suspended for the Extraordinary Regional Partnership Board to move forward with the three statutory partners making the decisions.
Officers clarified that the Regional Partnership Board was set up to look at health and social care across the Swansea Bay Region, the Extraordinary Regional Partnership Board commissioned the circulated report and the West Glamorgan Partnership is the general name for the region, over and above the health and social care area.
It was added that the report was the first of its kind in Wales to critically look back as a region to the response to COVID 19 in care homes, however it was likely that there would be many more to come as there was a clear focus on this issue across Welsh Government, the UK and Europe.
Members were informed that the West Glamorgan Partnership had maintained a comprehensive database of interactions with care home community, across all aspects including testing and pastoral support and that it covered a lot of the detail that supported the report. It was added that this level of information would be important when future reviews take place, although Professor John Bolton, on behalf of Welsh Government, was already carrying out review work which the partnership statutory directors had contributed towards.
It was stated that the main focuses of the review were on assurance, had the partnership complied with existing guidance throughout the process; and learning, what had been learned and would better preparations be put in place in case of a second wave and/or similar events in the future.
In regards to the status of the report, it was highlighted that it had been commissioned and would be delivered to the three individual statutory bodies for them to identify what further work and/or scrutiny needed to take place and what further evidence or lines of enquiry should be pursued. It was mentioned that the report does demonstrated very strong partnership working between Swansea Council, Neath Port Talbot Council and the Health Board; all of the key issues had been agreed across the parties, which will be important when the reviews take place.
It was noted that the report showed that strong assurance could be had in terms of complying with existing guidance, although there were occasions where guidance was changing rapidly that there was small delays between; however this was stated to be down to logistics and not failure to comply with the guidance. It was stated that another factor that could be strongly demonstrated was the clear evidence that leadership had sought to influence national policy and guidance, in light of the current situation in communities, and challenge guidance where appropriate. Members were informed that there was evidence which showed on occasion, local activity in the region had resulted in the updating of guidance and implementation of changes in how issues were managed.
The challenging areas were discussed with the greatest challenge across the UK, Wales and the region being the transfer of infection between sectors for example the emptying of hospitals in preparation for the COVID 19 patients. It was mentioned that where patients were transferred to care home settings, infection did occur and it was an issue that would need to be addressed nationally.
In summary, it was highlighted that capacity creation and the ability to move structures around depending on what was needed at the time, across the system was much better now than it was in March 2020, therefore making the service area better prepared if there was to be another surge of the virus. In terms of infection control and prevention of the spread of infection, it was noted to also be much better placed as practices and procedures had evolved and developed over the past few months.
Members asked was there any information as to how many people were infected after being admitted to hospital as it was known that those who didn’t have the virus when admitted to hospital, contracted the virus following admittance. It was also asked how many patients had the virus after being discharged from hospital. Officers stated that there weren’t any figures available due to the fact that at the beginning of the pandemic tests weren’t being carried out, so weren’t aware of how many people had contracted the virus; although tests had since been carried out, the figures wouldn’t be accurate or reliable due the lack of testing at the beginning.
Within the circulated reported it stated that despite national pressure to not be so transparent, the Regional Partnership Board publicly launched a revised social care eligibility criteria, to which Members mentioned that the revised criteria could be considered as being high risk, therefore wanted to know what monitoring had subsequently been carried out in respect of the revised criteria, keeping in mind that social care was a statutory requirement. Officers reassured the Joint Committee that statute and guidance had been complied with at all times; it was mentioned that the law did change at the beginning of the pandemic and changed the ability within adult services to look at cases differently. It was highlighted that the eligibility criteria was a document that set out how staff would need to respond if another surge was to arise, which was a way to keep Members and the public informed of the plans if that were to happen. It was explained that in Neath Port Talbot all of the adult services cases were rated via a Red Amber Green (RAG) system which was a form of preparation and proportionate response; green being the cases where negotiations had been made with family and friends in which they would start to provide care and support, amber being heightened risk if services were to be withdrawn and red was no possible way to withdraw services. It was mentioned that there was never a time where all of the green rated cases needed to be switched off, however Officers wanted to make it clear in the eligibility criteria that they would be prepared to switch the green rated cases off if the demand and surge came that they were expecting. Members were informed that even though the individuals were on a RAG status, staff were in touch with them on a daily/weekly basis and were still maintaining contact even though the visits weren’t being carried out at the time. Following a question in relation to how long the revised criteria would be in existence, Officers confirmed that the service was still in an adaptive phase and preparing for different possibilities, however if there was a need to enact any part of the eligibility criteria, Officers would be prepared to inform the Committee of what had been done, when it would be done and for how long it would be in place.
Members queried why the report did not reflect the experiences of the residents, families and staff of the care homes and asked if any attempts were made to contact those affected or their advocates, as it was stated that the opportunity needed to be provided to them to ensure that their voices were heard. Officers explained that an externally commissioned care group was set up as a sub group of the silver command group, which was made up of commissioning officers across the region who were in constant communication with the residential care homes and receive their input, which overall does have an impact on the delivery of services. It was clarified that the circulated report was a snapshot whilst in the midst of the pandemic, to identify lessons learned including the decisions that were made and the way in which those decisions were analysed. However, Officers expressed the need for a report to be collated and presented to Members, which would cover the views of care homes and their residents. Angela Thomas, Head of Adult Services, agreed to produce the report.
A discussion took place in relation to pastoral care and what lessons had been learned from isolating residents and patients from their families; it was asked would there be any changes to visiting and information given to relatives, including the way in which funerals would be managed, in the future if a second surge was to occur. It was stated that throughout the pandemic, staff recognised that they were balancing risks, the risk of infection against the risk of isolating people from their families who may have been at the end of their life. Officers highlighted that they have tried to manage the risks as effectively as possible, whilst following the guidance from Welsh Government. It was mentioned that care homes had been very innovative in trying to get their residents to have contact with their families for example through digital channels including Microsoft Teams and WhatsApp and where possible, allowing families to have contact by standing outside. Members noted that the circumstances were not ideal, however due to the uncertainty of the virus being airborne and the effectiveness of face masks, these measure had to be taken to prevent the risk of transferring the virus in care homes. The lessons learned were stated to be that there were other ways to provide contact between families to help prevent the spread of the virus, but the decisions being made on a day to day basis were very difficult and the decisions could only be made on a balance between the risks and the guidance being provided from scientists. It was added that the majority of the time when implementing the severe restrictions, authorities were being guided and instructed by Welsh Government with services such as cemeteries and crematoriums and that the social distancing measures, which was still a law in Wales, needed to be complied with to also help prevent the spread of the virus.
Reference was made to the key issues surrounding PPE, to which it was explained that based on the guidelines that were being issues at the time, the authority was complying with all PPE requirements; due to the continuous changes that were being made by the Government, the authority also had to re-evaluate decisions that were made. It was noted that the current annual spend in Wales on PPE was £10 million, however in the first three months of the pandemic the Welsh Government had spent £200 million trying to provide efficient PPE. Members were informed that during the pandemic there was a point where Wales was very close to running out of PPE, but as a region worked together and used regional processes to purchase and obtain PPE either through the usual channels or by sourcing it independently. It was mentioned that in the Neath Port Talbot area, there was capacity to supplement the care homes and other areas, with sufficient PPE and there was now a factory in Neath Port Talbot which had changed their manufacturing process to solely produce PPE and it was now the largest manufacturing PPE company in the UK. Following on from this, Wales became so efficient with PPE that the country started to supply other nations within the UK including Northern Ireland and England.
In relation to decision making, it was asked if it could’ve been done differently in order to have provided less impact on the community. It was stated that the purpose of the overview was to identify what could’ve been done better, however based on the information and advice that was being communicated from the Government and the evaluations completed by officers, the best possible decisions were made at the time; when the guidance, legal advice and science was changing, the authority adapted their processes and decision making.
Officers were asked if they would be able to provide the figures of how many people were infected with the virus in the care homes so that Members could gain understanding of how many elderly residents overcome the virus. It was noted that Officers could provide Members with this information if it was necessary.
Members made reference to the joint partnership with Public Health and asked for clarity on how the recommendations would be monitored and how they would be provided with reassurance that this work was being completed. Officers highlighted that Swansea Council and the Public Health Board would be going through the same process of scrutinising the circulated report. It was added that the partnership working around this had been effective and this would continue to be able to hold each other to account and work out common solutions; with meetings being held on a weekly basis, which had allowed the partnership relationship that had been formed to strengthen.
The Committee was informed that although testing sits directly within the NHS remit, there were now arrangements for national testing plans, issued by Welsh Government, and local testing plans in which the local authority representatives would be directly involved with; therefore, there would be local partnership arrangements with direct input into the development the plan.
Further discussion took place in relation to testing and ways to improve the reliability of the results and the speed in which individuals receive their results back. It was noted that there were two testing mechanisms, local testing which is carried out by the Health Board and a national self- administered test; the local testing was stated to be working efficiently with test results being returned in a timely manner. However, the national testing was often problematic with individuals struggling to receive their results; it was noted that this had been relayed back to Welsh Government by Directors of Social Services and the Health Board. Officers mentioned that having individuals’ complete double tests for the purpose of reliability, would likely put a burden on both mechanisms of testing, especially as the local testing was already under some pressure. It was confirmed that an All Member Seminar on Test, Trace and Protect was scheduled to take place in September.
It was noted throughout the report, there were references made to the principle of ‘not knowingly transfer of infection’; Members asked if officers could expand on this and confirm if the principle was unique to the Extraordinary Regional Partnership Board members or did it apply to all members. Officers explained that this was an important principle, which could have possibly been implemented sooner; it began with not discharging someone into a care home who was known to be infectious, and then moved to not discharging someone into community settings who was known to be infectious. It was noted that the region was ahead of Welsh Government guidance and one of the only regions to implement the principle at the time.
Detailed in the circulated report it stated that some clinicians continued to operate on the basis that once an individual was medically fit for discharge (MFFD) they could be transferred to a care home setting, even if still COVID positive; Members asked if they could receive assurances that if a second surge was to happen, that this problem would be resolved. It was highlighted that there were now checks and balances in place to ensure that this does not happen, for example ensuring up to date tests were undertaken; although it was stated to be difficult to manage due to it being a large system, officers were more reassured going forward.
Officers were asked if there was any forward thinking taking place in relation to where positive COVID 19 patients would be placed if there was a second surge, as it was recognised there could be risks for them staying in a general hospital or care homes. It was noted that at the moment the number of patients with the virus is very low, which had created its own difficulties, however placement of patients was at the forefront of thinking and if a second surge were to happen cohort of patients would be placed into particular COVID 19 wards and the field hospitals would be utilised.
Members asked for clarification on the conclusion of the circulated report where it stated that there were a number of areas, notably national NHS capacity-creation, where assurance could not be given in relation to the transfer of infection or harm. It was noted that earlier on the in pandemic, one of the main pressures on the NHS and the social care system was to empty hospital beds and that the then existing guidance relied on that it was safe to discharge patients into the community and if they were infected with the virus they could self-isolate. It was noted that this was a huge managerial pressure across the UK; as routine testing wasn’t in place and pressures were to empty hospitals, which meant that people who were infected moved around the system, both coming in and out of hospitals.
Following scrutiny, it was agreed that the report be noted.
On behalf of the Social Care, Health and Wellbeing Scrutiny Committee, the Chair thanked and passed on appreciation to all those working in the care sector, from officer level to the front line workers.