Introduction
Drawing on the findings of phases 1 and 2 and in collaboration with multiple stakeholders, we developed a toolkit of evidence-informed guidance and resources to support social distancing and isolation for CH residents (see Chapter 2 for method).
Participants
Two online, half-day, participatory workshops were convened. A total of 27 external members were recruited, comprising 10 PPI group members, 10 CH staff (7 CH managers/deputy managers, 1 team leader, 1 care worker and 1 practice development facilitator), 1 Associate Director of Nursing of a large NHS Foundation Trust, 3 professional representatives from the Steering Committee and 3 professional representatives from the Data Monitoring and Ethics Committee. Details of the external members who were able to attend each workshop are provided in Table 5.
| Workshop 1 participants (n = 22 including project team members) | PPI group members × 7Care home manager × 2Care home team leader and care staff × 2Associate Director of Nursing × 1Prof of Social Welfare (Chair of Data Monitoring and Ethics Committee) × 1Chief Nurse for Adult Social Care (Chair of Steering Group) × 1Project team members × 8 |
| Workshop 2 participants (n = 20 including project team members) | PPI group members × 9Care home manager × 1Associate Director of Nursing × 1Director of Clinical Services (Dementia UK) × 1Prof of Social Welfare (Chair of Data Monitoring and Ethics Committee) × 1Project team members × 7 |
Co-design events
At Workshop 1, participants discussed the study findings with reference to several trigger questions (see Appendix 2). A synthesis of this workshop is presented in Table 6.
| Initial thoughts about the findings | Audience for the toolkit |
|---|---|
| Can create positive impact for CHs caring for older people – need to reach key stakeholders, including DHSC, LAs, CQC, MPs to contribute to policy and integration of health and social care.The contribution of nursing to caring for older adults living in CHs is communicated powerfully. To consider – can professional judgement be mobilised in the toolkit?A programme of psychological support for residents and their families/friends is needed. Many families and friends have been traumatised.A programme of psychological support for a traumatised CH workforce is needed for, for example, restorative staff supervision.‘Like soldiers in the front line with no training’. It needs to be understood that CH staff are also grieving the loss of how CHs were before COVID-19. Staff may feel that their identities have changed since the pandemic. Coming out of the pandemic has been harder than going into it and there needs to be advice in the toolkit on both beginnings and endings of pandemics. | Residents – achieving person-centred care during a pandemic.Helping CHs to care for residents with diverse needs, for example those living with a cognitive impairment.Helping CHs to help families and friends to understand the requirements – including managing conflict.Empowering for managers – to say no.How to cater for CHs with no manager in place – who can read and use the toolkit in the absence of stable leadership?Incorporating best practice from the toolkit into the audit process, for example for CCG, CQC. For example, sitting alongside tools such as Restore2 and other guidance, for example British Geriatrics Society. Get the toolkit recognised as best practice so that it can be recommended by key agencies/stakeholders. |
| Include practical examples from the data about what has worked well/not worked well and why.Safety versus choice and control identified as a priority area.Care homes need greater autonomy – not permitting families/friends to hug residents is an example – ‘I don’t believe it will cause COVID’. Blanket rules do not work in settings that are so unique. The toolkit needs to empower people to come up with innovative solutions to problems. How can we keep things more collaborative in the future and less dictatorial? Now CHs have lived through the pandemic, how can we develop a more collaborative approach to assessing risk? | |
| Purpose of the toolkit | Format of the toolkit |
| Helping CH staff communicate with families and other health and care professionals. For the future, CHs need to have a greater explanation of the ‘whys’ so that they can tell residents and families more about why interventions need to be implemented.Facilitating CHs to communicate well with residents.A resource for staff when the manager is not there.A resource for staff undertaking additional roles.Guidance regarding managing staff absence, sickness, agency staff.How can we support managers and the loneliness of this role?Contributing to quality of care for residents – different aspects of their lives (Adult Social Care Outcomes’ Toolkit – ASCOT).Making the job easier for CHs – not a stick. | Short, to the point, plain language, not academic.Printed and digital formats.A film would be better than paper, but different audiences might need different formats.A one-size-fits-all toolkit would not meet everyone’s needs – CHs are very diverse, for example some may not have a PC or only for the use of managers, others may have virtual technology systems in place with multiple devices to inform resident care.Important for the toolkit to join the best platform – use what is out there. |
Overview of Workshop 1 discussions
These data sources and discussions informed the development of the draft content, which was organised around six areas, grouped into three sections:
- Section 1 – Caring for Residents: caring for residents when they are social distancing; caring for residents when they are isolating.
- Section 2 – Caring for Families and Friends: supporting residents, families and friends to communicate when visiting is not permitted; supporting visits from families and friends when visiting is allowed but with restrictions.
- Section 3 – Caring for CH Staff: caring for care staff; caring for managers.
For each area, ‘consequences’ and ‘actions to consider’ were presented with illustrative data extracts and case studies.
This draft content was the focus of Workshop 2; a synthesis of Workshop 2 discussions is presented in Table 7.
| Key area 1: supporting the well-being of residents who are social distancing | Key area 4: supporting visits from families and friends when visiting is restricted |
|---|---|
| On the difficulties of masks and communications, visors and clear masks were noted to be better for communications. However, there are associated costs. Consider adding the availability of visas and clear masks to actions.On the same point of communications, consider contacting the deaf society/other organisations for advice on types/suitability of masks.There was a feeling that actions are all targeted at managers, which increases their workload. There is a need to highlight the importance of ensuring time, training and resources with indications towards costs. This was felt to be particularly important considering the significant turnover of managers observed during COVID-19.Well-being should cover people going out of CHs, for example for religious or cultural activities that are deemed essential even during restricted movements.For residents with a cognitive impairment, processing, understanding and retaining information are key for the well-being of residents. Perhaps a suggestion could be to create bubbles or support groups to maintain information. Some CHs have already introduced cohorting and support bubbles, but these can be difficult due to the diversity of residents and their needs.Acknowledge the challenges associated with CH design, maybe the toolkit can consider short-, medium- and long-term actions.Need to acknowledge the legal responsibilities placed on managers.The importance of care planning to record residents’ wishes and choices. Need more on how to support staff completing the care plans to ensure actions are individualised to needs.Is there a way/room to suggest some actions that do not require the managers’ input, for example self-organised by staff? Links back to the workload and burden placed on managers. However, there was an appreciation that some managers might not be doing some of the actions and hence it is good to keep most of them.Need to mention governments’ responsibilities. | For approaches to facilitating in-person visits from families and friends, make it clear what was reported as working well/not working well, for example the intelligence is that drive-by visits and window visits did not work well for families/friends and added to frustrations.Move to the CH staff section the point about increased staff workload because of visitor restrictions and point regarding the impact of visiting restrictions on the psychological well-being of CH staff.Move to CH staff and manager sections the point about CH staff experiencing guilt around maintaining visitor restrictions.The need for CH communication with families/friends to be upfront and transparent about current guidance for visiting.Over-interpretation of visiting guidance so that CHs are doing different things despite being in the same area and being regulated in the same way – variation and inconsistencies.Psychological support for families and friends who have faced trauma, including the death of a resident.Guidance for families/friends of an older person moving into a CH, for example making it known to families and friends that they may lose their right to visiting their family member.How CHs manage EoL care.Essential caregiver role – need to capture this in the toolkit. There may be more rights coming into law related to this that we must be cognisant of.Promoting resilience – moral injury. |
Overview of Workshop 2 discussions
A third and final co-design activity involved sharing a further version of the draft content of the toolkit with stakeholders drawn from Workshops 1 and 2 [PPI group members × 10, CH managers × 2, Associate Director of Nursing × 1, Director of Clinical Services (Dementia UK) × 1, project team members × 8]. The final draft toolkit (presented in Appendix 5) comprises a section for Residents, Families and Friends, and CH staff with each section addressing two key areas. For each area, content is organised around three headers: ‘what is the issue?’, ‘what we have learnt’ and ‘you could try this’. Data extracts and case studies are incorporated and links to resources and organisations (see Boxes 1 and 2 for examples of the key areas related to caring for residents). The toolkit is intended to be used flexibly with staff, residents, families and friends to support health and care delivery by the following:
- contributing to person-centred care for residents, families and friends by providing evidence-informed guidance for social distancing and isolation of residents and related restrictions;
- support CHs to care for residents with diverse health and care needs (e.g. those living with dementia);
- support CHs to communicate well with residents, families and friends, and health and care professionals;
- help direct focus on staff well-being;
- help make the job easier for CHs during a pandemic;
- help inform care for other infectious diseases.
The toolkit will be free to download from the project webpage, and the film will be free to view from the project webpage.
Caring for residents when they are social distancing
Caring for residents when they are isolating