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This first insight document focuses on adult social care: reviewing data on outbreaks, deaths and availability of personal protective equipment (PPE), and in particular highlighting the impact of COVID-19 on staff wellbeing and the financial viability of adult social care services. It describes the need – now more acute than ever – for whole system working across different sectors to ensure safer care. It also outlines future areas of focus, including infection control both within and between services, how local systems are engaging social care organisations in the management of COVID-19, and how care for people from vulnerable groups is being managed through the crisis.

I was employed as a healthcare assistant in a care home, where I worked for about three months. During this time, I found out that patient safety and quality of care were undermined by healthcare assistants, and the management and the nurses did not seem to realise it. Examples included: Carers were given a box of gloves each and they were expected to use them for up to two weeks. When asked for more gloves, the manager would check the last time they took a box of gloves and would question what they had done with the last ones they collected. In order to save the gloves, carers used one pair of gloves to deliver personal care to three to five residents before changing them. They would take the rest of the gloves home and bring them back to work in the next shift. Genital care was totally neglected. Residents’ genitals were not cleaned. I spoke to a nurse in another unit about this and all she said was she thought it was being done. When carrying out personal care to one lady, I found dried faeces wrapped in her pubic hair which took me a good number of minutes to clean. When I finally finished doing it, the lady pointed at her private part and said to me “it can breathe now” and when I asked why, she said “because it has been washed”. Infection control. One of the problems was that there was never any soap in the bathrooms and places where there were wash hand basins. So, after personal care, especially after caring for residents who had opened their bowels, we could only wash our hands with clear water. Hand sanitiser dispensers were hanging empty with no sanitising gel, so no opportunity for either visitors or staff to sanitise their hands whilst in the care home. Healthcare assistants apparently had no clue about catheter care, even those working at the nursing unit where there were a few residents that had catheters. I never saw any of them doing catheter care and one day when I was doing it, my colleague was really frightened, held my hand back and said I was going to pull the catheter out. Most of the times when residents opened their bowels, carers would either clean it very shallowly, or they would only take out the soiled pads and replace them with clean ones without cleaning the area at all. As such, when you took over the shift, during the first checks you would think that a resident had opened bowels but find out that the pad was dry and clean at that moment, but the faeces on it and on their skin was dried up. Oral and nail care was another issue. Carers never did oral care, and those who bothered to document would say “resident denied oral care”. Some of the residents’ beds were not functioning, especially in the nursing unit where most of the residents were bed-ridden. This meant that healthcare assistant staff had to bend and strain their backs each time they were giving personal care, which would lead to backaches. After trying to share my concerns on the above issues with three nurses to no avail, I was only left with the choice of talking to the management. I wrote a letter of observation, accompanied by some recommendations. I ended my letter by letting the management know that I was ready to discuss my concerns with them at any time. They did not call me up for any discussion. A change in behaviour... A few days later I started noticing a change of behaviour from all staff towards me. Most of them did not talk to me, many times I found out that people were whispering things about me as when they saw me approaching them they would stop talking. One unit reported that I was very slow, and I was never assigned to work there anymore. People ignored me when I tried to join in a conversation. Each time I was working, nobody would let me do personal care. I was only allowed to work as an assistant to fellow healthcare assistants. In some rooms where I went in first and started doing personal care, they would tell me that I was taking too much time. My opinion on anything did not count. One day when I came to work, there was a small problem which needed to be fixed between one of the nurses and myself, but she refused to listen to me and insisted that I should go back home. I went home as she had asked, and the next day I called and told the manager that I was sent home last night. He started blaming me based on what the nurse had told him, which was not true, without listening to my own side of the story. I insisted that he should call a meeting where he could listen to both of us, because what the nurse had said was untrue. His response to me was that I would need a reference from him so I should be careful about the way I did things. However, he finally accepted and we agreed on a date for the meeting. But when it came to the day of the meeting, the nurse was not there. I explained myself to my manager, in the presence of the secretary. His response to the letter I wrote with my concerns in was that he appreciated it, but he thought that the care home was not the right place for me, and that he thought that I was too qualified for the job. He suggested that everybody felt threatened with my presence. I told him that that it sounded to me like he wanted to remove me from my job; a job which I very much wanted to do. When I came back for the next shift, I discovered that my shift had been cancelled and I had been replaced by someone else. I spoke to a senior carer who called my manager and he told me that he was not expecting me to come to work because of what had happened the other night. I went back home. The next day he called and told me that after due consideration, he had decided to extend my probation time to a further three months, and that I should compose myself, come to work and do only what I was expected to do. Psychologically tortured As I continued working, things got worse each day. I experienced colleagues laughing at me, talking about me, not talking to me, ignoring me; the list could go on and on. I was psychologically tortured. I developed a violent headache. Each time I thought I was going back to work I felt sick, got palpitations, felt so hot as if I had fever, at times shivering, with painful nerves. I kept asking myself whether I was wrong to have done what I did. I did a lot of self-counselling and told myself that I was going to stay at the workplace if I was not dismissed. This was because I was planning to write more letters. I had only highlighted a few of the many issues in my first letter. My hope was that one day someone was going to understand me and things would improve. One night I stopped a colleague from putting a pad on a resident she had not cleaned properly. I cleaned the resident and did vaginal and catheter care, before putting on the pad. There was another resident who was very wet, from their pyjamas to the bedding; my colleague wanted us to only change the pad and let the resident lay with the wet clothes on the wet bed “since they were going to wash her in the morning anyway”. This was the 1am check, and I argued that I could not imagine her being able to fall asleep in that condition. We ended up changing the resident’s pyjamas and putting a towel and an extra pad on the bed to make her feel comfortable. Forced into resigning My colleague became angry with me. I was surprised because I had done nothing wrong. There was altercation and she confronted me. I couldn’t tell anyone as no one would believe me. I felt excluded and alone and the only thing that came to my mind was that I should resign. When I finished work in the morning I went and told my manager that I was resigning. He told me that I was expected to give two weeks’ notice and that I should write my resignation letter that day, which I did. He told me it was rather unfortunate that it hadn’t worked out for me in the care home… Did I do the right thing? What would you do?

Under the Equality Act 2010, public sector organisations must make changes in their approach or provision to ensure that services are accessible to disabled people as well as everybody else. This series of guidance shares information, ideas and good practice in making reasonable adjustments for people with learning disabilities in specific health service areas. It is aimed at health and social care professionals and family members who provide support for, or plan services used by, people with learning disabilities. There is also an easy-read summary for each service area.

This quick guide includes information on: capacity and consent, what the process is if there is a decision to give medicines covertly, and what to do if you need to make a decision urgently.

Eastern AHSN provided Quality Improvement (QI) coaching to the nurses employed by South Norfolk Clinical Commissioning Group (CCG) to work with residential and nursing homes across central Norfolk and Waveney to support the implementation of the checklist approach. The overarching aim was to reduce avoidable admissions to hospital from care homes. The Eastern AHSN believes this successful project is an easily replicable approach to the improved management or prevention of UTI and can directly impact by not only improving patient care with the added benefit of admission avoidance and reducing unnecessary clinical call outs. Successful results and benefits: At the time of writing, 700 staff from 104 care homes across Norfolk have been trained in the management and prevention of UTI and how to complete the UTI checklist. Unplanned emergency admissions have reduced by 22% and a reduction in antibiotic prescribing has been seen within this cohort of care homes. Staff reported increased confidence in the management and prevention of UTI. Data from the checklists highlighted that a lot of UTIs were related to catheter management and obtaining samples from the bag, which became increasingly preventable from the change in treatment. Care workers were assuming residents had an UTI, but after the teaching sessions they realised it may be dehydration that could present the same symptoms and commenced re-hydration. If an UTI is suspected then the staff were taught to initially think dehydration and to increase fluid intake then to reassess the patient prior to making call outs. Care homes are not now doing routine urine dipsticks or using urine dipsticks as a diagnostic test to diagnose UTI’s which has improved our diagnosis of UTI. Feedback from care homes and primary care has been very positive with one care home manager emailing to say: “The UTI checklist is definitely used at our nursing home and we have noticed a positive difference since we started. Thank you for your support.”

Key outcomes UTI hospital admissions reduced by 36% in the four pilot care homes (150 residents). UTIs requiring antibiotics reduced by 58%. The gap between UTIs increased from an average of nine days in the baseline period to 80 days in the implementation and sustainability phase. One residential home was UTI-free for 243 consecutive days. Similar outcomes noted in pilot 2 care homes (215 residents).

What will I learn? How the QI project was set up Case studies on other QI projects

This study confirmed that the most influential factors in the decision to use assistive devices for patient transfers are time constraints and difficult patient-handling situations. These factors lead to infrequent use of assistive devices, especially mechanical devices that are difficult to retrieve or not readily available.

This page by the Academic Health Science Network includes a case study and a video demonstrating the triage in action

This editorial by Dr Michael Farquhar, published in Anaesthesia, explains the importance of taking breaks while on shift and ensuring a good sleep between shifts and the inextricable link between sleep and patient safety.

This toolkit includes: The Productive Leader The Productive Ward The Productive Mental Health Ward The Productive Operating Theatre Productive Community Services The Productive Community Hospital Productive Endoscopy If you work in the NHS or social care you can access online (downloadable PDF) versions of the boxsets free of charge. To get your copy, email england.si-communications@nhs.net.