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Today HSIB has published a new national intelligence report, Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response.[1] This looks at inconsistencies in the guidance on PPE requirements for care workers visiting ‘clinically extremely vulnerable’ individuals at home. The report is in response to a member of the public raising concerns when visiting a patient at home in the ‘clinically extremely vulnerable’ category. They noted that while they were visited by district nurses in PPE, their care workers did not wear this, advising that this was not required. The patient later died, and their death was confirmed as COVID-19 related. HSIB found that during April the guidance made available by Public Health England for care staff in this regard was inconsistent. While the primary guidance did not refer to the need to wear PPE when visiting ‘clinically extremely vulnerable’ individuals, other guidance issued in the same month did set out these additional safety provisions. As a result of this, multiple versions of the guidance were available to care workers, who would not be aware of the PPE requirements if they referred to the earlier version of this. Speed of the response HSIB state that they brought this to the attention of Public Health England on the 28 April 2020. They subsequently replaced the primary guidance with a link to a version with the additional PPE provisions on the 13 May. Given the importance of clarity on infection control and PPE, it is very concerning that the conflicting guidance remained live on the gov.uk website for a further two weeks after the issue was identified. A wider system issue The report acknowledges the complexity of providing and keeping up to date such a wide range of guidance, particularly in a crisis scenario, noting that this creates “a risk that patient safety issues may be missed”.[2] When considering the learning potential of this case, HSIB suggest that “there is an opportunity to introduce a document management system for guidelines to ensure that the latest information is available”.[3] While this specific issue is now resolved, it is disappointing that there is no wider recommendation relating to the systems risks above identified by HSIB. Patient Safety Learning believes that there should be an additional recommendation on this that clearly identifies the relevant healthcare bodies responsible for looking into this. There are also questions about how updated guidance is published and shared. Commenting on this in The Independent, Jane Townson, Chief Executive of the UK Homecare Association, mentioned problems with guidance being updated late at night with little notice.[4] She also stated that “there was a very high risk that care providers were not alerted to the changes unless they belonged to a membership association”.[5] Who can lead this change? While we have noted Public Health England's specific role in this case, formulating this type of guidance can involve a number of bodies across the UK, such as: Department of Health and Social Care NHS England and NHS Improvement Public Health England Public Health Wales Public Health Agency Northern Ireland Health Protection Scotland When system-wide patient safety issues arise all these organisations have a role to play. We know that when it comes to implementing changes the system is “confused and complex, with no clear understanding of how it is organised and who is responsible for what”.[6] Patient Safety learning believes it is vital that there is a clear approach to addressing such underlying safety issues. We need to ensure that learning and recommendations for change are prioritised and implemented widely across the health and social care system. References Healthcare Safety Investigation Branch, National Intelligence Report: Personal protective equipment (PPE): care workers delivering homecare during the COVID-19 response, August 2020. Ibid. Ibid. The Independent, Coronavirus: ‘Confusing’ advice from Public Health England put patients at risk, watchdog says, 26 August 2020. Ibid. Care Quality Commission, Opening the door to change: NHS safety culture and the need for transformation, 2018.

Key findings The survey responses confirm that for the majority of respondents, the pandemic has been a very challenging experience. They indicated that their work and wellbeing has been worse or much worse than at normal times, during the survey period. Having to accept patients from hospitals with unknown COVID-19 status, being told about plans not to resuscitate residents without consulting families, residents or care home staff, lack of guidance on issues like personal protection and issues of poor access to pay if they became ill were some of the major issues the care home workforce faced during March and April 2020. While two thirds of respondents said they ‘always’ had access to appropriate personal protective equipment (PPE) and most others said that it was usually available, a small minority were not provided with PPE and had to improvise, by obtaining it themselves or by making it. The need for appropriate PPE in care homes is of critical importance in staff and resident safety: 21% of respondents said that their home accepted people discharged from hospital who had tested positive for COVID-19. The majority of survey respondents found it easy to access hospital care for their residents when this was required; however, a substantial minority found this difficult or very difficult. Additionally, a substantial number found it difficult to access District Nursing and GP services, which are universal parts of the National Health Service. In addition, many indicated that they were not able to access essential training from other health professionals at this time. Some respondents refocused work to consider how they could improve on their approach to end of life care. Worryingly, some who responded raised serious ethical and professional concerns, for example GPs, Clinical Commissioning Groups and hospital trusts making resuscitation decisions without first speaking to residents, families and care home staff or trying to enact ‘blanket’ ‘do not resuscitate’ decisions for whole groups of people.

In April HSIB identified an emerging safety risk of confusion over guidance on PPE requirements after a case was referred to them by a member of the public. Care workers had visited the home of a ‘clinically extremely vulnerable’ patient and did not wear PPE. The patient later died and the death was confirmed as COVID-19 related. The report emphasises that the patient was not showing symptoms of the virus when the care visits took place. The guidance available at the time found that Public Health England’s (PHE) primary COVID-19 guidance for home care provision, published on 6 April, did not reference the PPE needed when caring for those within the most vulnerable groups. On 2 April, separate Official UK Guidance on PPE had been published for those working in outpatient, community and social care settings but was not linked to the PHE primary guidance and not easily accessible. Public Health England then issued newer guidance on 27 April (how to work safely in domiciliary care in England) which did include PPE provisions for the ‘clinically extremely vulnerable’ group. However, the original (6 April) guidance was still live and available and did not reference the new update. After HSIB highlighted the case and the associated safety concerns to Public Health England, they withdrew the link to the primary guidance and provided a link to the newer guidance. Medical Director, Dr Kevin Stewart said: “Guidance that protects frontline workers and vulnerable patients needs to be as clear and accessible as possible and this is even more important in times of crisis. However, there are multiple guidelines for different care sectors and it is easy to see where confusion can occur as new updates overlap with older versions. Our report recognises the challenges in implementing national guidance and that further work is needed to understand the most effective systems that would enable better version control. Whilst our analysis focused on PPE guidance for carers working in homes, the risk to patient safety because of poorly communicated guidance is applicable across all healthcare settings. Our aim is to identify specific safety risks for COVID-19 and share that insight as widely as possible to aid the decision-making process and ensure consistent care for all.”

Key points: The coronavirus (COVID-19) pandemic has had a profound impact on people receiving and providing social care in England. Since March, there have been more than 30,500 deaths among care home residents than we would normally expect, and a further 4,500 excess deaths among people receiving care in their own homes (domiciliary care). There has been a greater proportional increase in deaths among domiciliary care users than in care homes (225% compared to 208%). And while deaths in care homes have now returned to average levels for this time of year, the latest data (up until 19 June) shows that there have continued to be excess deaths reported among domiciliary care users.Social care workers are among the occupational groups at highest risk of COVID-19 mortality, with care home workers and home carers accounting for the highest proportion (76%) of COVID-19 deaths within this group. During March and April, there was a substantial reduction in hospital admissions among care home residents. Elective admissions reduced to 58% of the 5-year historical average and emergency admissions to 85% of the 5-year historical average. By reducing admissions, care home and NHS teams may have reduced the risk of transmission, but there may have also been an increase in unmet health needs. During March and April, discharges from hospitals to residential care homes were 75% of the historical average, while discharges from hospitals to nursing homes increased to 120% of the historical average. These difficult decisions to discharge patients were made in an urgent and uncertain context but may have played a role in transferring risk to a poorly supported social care system.