Specific Recommendations for Nursing Home Providers from the Covid-19 Nursing Homes Expert Panel Report

Introduction

The Department of Health recently published the COVID-19 Nursing Homes Expert Panel Examination of Measures to 2021 Report to the Minister for Health. The report contains a range of recommendations in line with lessons learned to date and international best practice that aim to protect residents in nursing homes over the next  year and into the longer term.

The Panel with responsibility for the development of the Report and the associated recommendations, recommends that the relevant Government Departments ensure that sufficient resources are assigned to the responsible Departments and agencies to ensure their timely implementation.

Below are the specific recommendations allocated within the Report’s recommendations to Nursing Home Providers.

Specific Recommendations for Nursing Home Providers

The thematic areas associated with the recommendations are:

Public Health measures

1. 1. Continue the enhanced public health measures for COVID-19 Disease Management in Long-term Residential Care (LTRC) adopted by NPHET at its meetings of 31st March 2020 and 3rd April 2020, including PPE supply to nursing homes; staff accommodation; contingency staffing teams; preparedness planning etc.

Infection prevention and control

1. 1. Each nursing home should adopt a clear IPC strategy, including deep clean protocols, for itself which should be incorporated into its preparedness plan. It should be reviewed regularly to ensure consistency with the HSE’s community IPC strategy.
   2. It is essential that in-house staff who can undertake sample swabbing and reliable labelling are available, and that there is proximal access to a laboratory with Laboratory Information Management Systems (LIMS) follow up for contact tracing for both residents and staff.
   3. Infection control training should be mandatory for all grades of nursing home staff.
   4. Nursing home staff should have access to ‘train the trainers infection control’ training programme approved by the HSE.
   5. Every nursing home requires onsite access to a trained infection control lead on each shift. That lead will ensure IPC protocols are implemented and will support staff to do so
   6. Each nursing home is responsible for and should have an emergency supply of PPE and other COVID-19 related equipment in the event of a cluster. This should be included in preparedness plans.
   7. Management of entry and exit: Examine options for zoning within care homes so different entrances/exits can be used for different parts of the home. This examination should be documented with results and actions incorporated into preparedness plans.

Outbreak management

1. 1. PPE to be readily available and staff training with onsite supervision on every shift to ensure PPE being used correctly. Training should be documented and records available for inspection by HIQA.
   2. Sustain protocols for self-isolation, quarantine, cohorting and referral to GP Lead.
   3. Suspect cases and close contacts need to be isolated pending the results of rapid testing.
   4. Facilities must have ability and space to isolate and cohort residents and a clear plan on how this will happen. This plan should be incorporated into preparedness plans
   5. Access to safe staffing levels at all times and to include required skill set on every shift.
   6. Social distancing facilities for residents and staff should be in place and maintained.
   7. Each provider should incorporate written plans on each of the above into their preparedness plan for review by HIQA.

Future admissions to nursing homes

1. 1. Ensure all new residents coming from the community or proposed transfers from hospital are tested for COVID-19 prior to admission.
   2. Admissions should only be made to nursing homes who can demonstrate their infection control measures are of sufficient standard to ensure there is no risk of onward infection. HIQA should maintain a register of those nursing homes it deems to have demonstrated sufficient infection control standard reached, to support informed decisions on admissions in this regard.
   3. New Residents must be isolated according to HPSC protocol.

Nursing home management

1. 1. Log of all persons/staff entering nursing homes should be maintained by each nursing home and available for inspection by HIQA.
   2. Nursing homes should have a clear written back-up plan when regular staff cannot work or fail to turn up for work. This should be incorporated into the nursing home’s preparedness plan for review by HIQA.
   3. All Healthcare Assistants (HCAs) should have a relevant QQI Level 5 qualification or be working towards achieving it. A phased pathway towards achieving this should be in place. The requirement’s inclusion in the regulatory framework should be considered.
   4. For the next 18 months or until the declaration of the end of the Global pandemic by WHO, staff employed by a nursing home should be precluded from working across multiple sites and adequate single-site employment contracts should be put in place to support this.
   5. Occupational health and HR support, including psychological supports, for all staff is necessary and access should be put into place

Data analysis

• No recommendations specified for Nursing Home providers

Community Support Teams

• No recommendations specified for Nursing Home providers

Clinical – general practitioner lead roles on Community Support Teams and in nursing homes

1. One of the GPs, already caring for their patients in a nursing home, will be appointed to the additional role as a nursing home’s GP Lead, and working with the Person in Charge and other senior nursing home staff will contribute to the nursing home’s general oversight and governance. The Person in Charge has overall responsibility for clinical governance.
2. The sessional commitment and remuneration for the post will be specified in a contract between the nursing home and GP lead; functions would include promoting the use of instruments like the InterRAI Single Assessment Tool and the Clinical Frailty Score and optimising medication management, ensuring full compliance with e.g. influenza vaccine uptake for residents and staff in the nursing home and close liaison with community services and outreach services of acute Hospital Groups
3. A clinical governance oversight committee should be established in all nursing homes and its inclusion in the regulatory framework should be considered – in the interim guidance on the role and composition should be developed. In time, one of the functions of this oversight committee should be to review quality indicator/resident safety reports and action appropriate follow up

Nursing home staffing & workforce

1. It is essential to have strong informed nursing leadership on site in all nursing homes with a documented contingency plan for when leaders are absent. These plans should be incorporated into preparedness plans. They should be available for inspection by HIQA.
2. Considering the nursing metrics and the HPSIR, a quality indicators and outcomes/resident safety model should be developed for nursing homes, requiring each nursing home to publish regular reports and to provide copies to HIQA. HIQA should establish a public register of all such reports provided by nursing homes, and oversight and validation checks should be incorporated into the regulatory framework.

Education

1. To promote the wider implementation of advanced healthcare directives (AHDs), education programmes, including some virtual, should be put in place and providers should facilitate greater staff participation.
2. Staff training and career development programme with a requirement that senior nursing staff will have undertaken post-graduate gerontological training and show general evidence of training competency. A phased pathway towards achieving this should be in place with clear targets set, and regulatory oversight provided to ensure that targets are met.
3. Mandatory continuing education for all staff in areas such as infection control, palliative care & end of life and dementia should be introduced and a phased pathway towards achieving this should be in place with clear targets set, and regulatory oversight provided to ensure that targets are met.

Palliative care

1. Every nursing home should be linked with the Community Palliative Care Team in their catchment area.
2. Visitor guidelines – individual assessments should be undertaken and documented, and compassionate visiting should be followed as recommended by the HSE and in line with HPSC visiting guidance. They should be available for inspection by HIQA.

Visitors to nursing homes

1. Infrastructural adaptations may be needed including visiting rooms that can facilitate visits from friends and family.
2. End of life visiting must be arranged on compassionate grounds based on clinical judgement and take account of public health measures.

Communication

1. Meaningful communications with residents and families should take place regularly in relation to visiting protocols, changes in processes and explanations relating to same.
2. Clear communication plans with residents to provide information on the ongoing situation should be developed and documented regularly. HIQA should examine these as part of the inspection process. Providers should provide regular updates about residents to the families.
3. Phone lines must be maintained and additional reception / communications staff planned for at busy periods. Purchase tablet computers if relevant and review IT solutions for use by individual residents to assist with family and friend communication and review of facilities to ensure all have access to Wi-Fi facilities. Each provider should document its review and action plan in this regard and make it available to residents, families and HIQA.
4. Dedicated staff should be assigned/appointed to facilitate social activities and communication with family. Assignments / appointments should be documented with clear activity and communication plans and records in place, and available for inspection by HIQA.

Regulations

1. There are currently 22 inspectors overseeing approximately 576 facilities with a visit frequency of 18 months. While onsite inspections are labour intensive, the frequency of these should be increased (allocated responsibility to HIQA)
2. Assessment of compliance with the regulatory assessment framework of the preparedness of designated centres for older people for a COVID-19 outbreak should be part of the inspection process (allocated responsibility to HIQA).
3. Provision should be made for regular mandatory reporting to HIQA of key operational data by each nursing home provider including data on staff numbers and grades, qualifications, occupancy levels. This data should be available to health agencies including the Department of Health to inform ongoing planning for residential care services. HIQA should ensure streamlined processes are in place for the collection, collation and reporting of such data.

Statutory care supports

1. Integration of private nursing homes into the wider framework of public health and social care should be advanced. This should be prioritised in the short-term with the implementation of the recommendations in this Report, and longer-term reform should be pursued as a key component of the intended Commission on Care.
2. HIQA and each nursing home provider should continue to highlight and promote independent advocacy services available to residents.

Download the Nursing Home Expert Panel Report

The full report, which details specific recommendations also for the DoH, HSE and HIQA can be downloaded from https://www.gov.ie/en/publication/3af5a-covid-19-nursing-homes-expert-panel-final-report/