Mental health and wellbeing of care home residents and staff: a snapshot of COVID-19 impacts and responses
The devastating impact of the pandemic on care homes throughout the UK has raised many questions – including the impact of lockdowns, visitor bans and so many deaths on the mental health of residents and staff. The situation is made even more challenging by the ‘fundamental gaps’ in care home data exposed by the pandemic
Author: Dr Kellyn Lee, Research Fellow in Ageing and Dementia at the University of Southampton
Headline finding: the pressing need for better care home data
It has long been recognised that people living in care homes are at an increased risk of mental health issues compared with age-matched groups who live in the community. However, Gleeson et al reported that, while people living in care homes have been found to have higher rates of depression, little information is held on the prevalence of, for example, self-harm and suicidal behaviour in this population, how this is measured, and how care homes respond to such issues.
In December 2019, Professor Chris Whitty, Chief Medical Officer for England and Chief Scientific Adviser for the Department of Health and Social Care (DHSC), noted that while ‘stunning advancements have been made in medical care predominantly within NHS settings, there is a lack of evidence-based research in social care’.
One year later at the height of the pandemic, a report by Burton et al found that ‘COVID-19 has exposed data failings that have hindered service development and research for years. Fundamental gaps in terms of population and service demographics, coupled with difficulties identifying the population in routine data, are a significant limitation.’
The report contrasted the availability of NHS health data during the pandemic – ‘systematically managed, with accelerated research permissions processes facilitating timely data research in primary and secondary care’ – with the lack of available care home data: ‘There is no equivalent system of governance for care home data, which is currently held by a mixture of private companies, regulators, and health and social care providers.’ It concluded that ‘the COVID-19 pandemic has exposed a critical knowledge gap for UK [care] practitioners, researchers and policymakers, driven by the absence of high-quality routine data for one of the most vulnerable groups in society.’
During the first wave of the pandemic, Hanratty et al highlighted that a lack of care data is not the full extent of problem: ‘It is [also] the number of different bodies that are collecting information, and the absence of standardisation and cross-sector cooperation in how data are collated, shared and used’ – this despite the fact that ‘a growing number of homes have sophisticated information systems to monitor medications, support care planning and much more’.
These findings were supported by the Royal Statistical Society in its recent report, which (among other recommendations) highlighted that: ‘Throughout the pandemic, there has been a lack of data regarding the situation in care homes in England. We do not know how many care home residents there are [and] there has been no data on the extent of COVID-19 testing in care homes … Care homes are run by a variety of organisations, so it is understandably difficult to collect data. However, Public Health Scotland has shown that it is possible to do more than has been done in England.’
Introduction: longstanding concerns about residents’ mental health
In the UK, social care operates largely in the private sector outside of government control, and therefore is separate from, and has no formal coordination with, the NHS. This somewhat fragmented structure is commonly held to be the source of many problems in the health and social care system.
The UK care home market ranges from large corporate organisations to not-for-profit organisations and family-run businesses. According to a 2018 Grant Thornton report on the UK care home market for over-65s: ‘The 10 largest for-profit providers make up under a quarter of the market, which is dominated by independent (non-public sector) operators. Around 38% of capacity is provided by smaller groups, with the remainder owned by operators with one or two homes.’
1. The mental health of UK care home residents pre-COVID-19
Even before the pandemic emerged, concerns had long been raised about the mental health of residents amid calls for a ‘social revolution in residential care’. Once a person moves into a care home, they may over time face many losses – from personal possessions to their independence and agency. Days are typically organised for them around ‘light’ activities, and they are likely to lack the means of communicating with the outside world independently.
An international systematic review of studies published prior to COVID-19 found higher reported rates of depression and suicidal behaviour in care home residents compared with matched age groups in the community. In the UK, the Mental Health Foundation suggests one-in-five older people living in the community experience depression or poor mental health, but that this number rises to two-in-five for those living in care homes. Assessing the few studies to have explored interventions relating to poor mental health (specifically, suicidal ideation) in care homes, a 2019 systematic review found that interventions are not rigorously evaluated and no conclusion could be drawn on their effectiveness. Validity and reliability are further complicated due to the large numbers of older people living in care homes with a cognitive impairment such as dementia.
Possible reasons for the under-identification by healthcare professionals of mental health problems in older people include stigma surrounding discussing mental health issues, and the perception of suicidal behaviours in older age. For example, if a person chooses to refuse food because they want to die, it is unlikely to be recorded as suicidal ideation or receive the same response by care staff, compared with a person attempting to take their own life using more aggressive methods.
2. The impact of COVID-19 on UK care homes
Across the UK, COVID-19 has had a shattering effect on many care home communities – despite the warnings that emanated from care homes in countries where the pandemic initially peaked earlier than in the UK; for example, Italy, Spain and Belgium.
As has been well documented, UK care home residents were extremely vulnerable to contracting and then dying from the virus, which entered care homes either via staff who were asymptomatic, or from new residents admitted directly from hospitals having unknowingly contracted COVID-19 there. Questions have also been raised about the extent that staff moved between different care homes, the ongoing use of agency staff, and the lack of testing available to care home staff.
A study coordinated by the University of Stirling and published in August 2020 found that of all COVID-registered deaths in the UK, 31% (17,127) had occurred within care homes, and at least 40% were accounted for by care home residents. Up to that point, 47% of deaths attributed to COVID-19 in Scotland had occurred in care homes, compared with 28% in Wales, 30% in England, and 42% in Northern Ireland.
While the study showed that Scotland had recorded the highest proportion of care homes affected by COVID-19 and the highest proportion of care home deaths attributed to the virus, it had a lower proportion of excess deaths in these facilities compared with England and Wales. Northern Ireland had the lowest share of care homes infected and the lowest level of excess deaths in care homes.
In terms of how these data were reported, Public Health England published weekly reports on care homes with suspected or confirmed outbreaks of COVID-19, and the Scottish Government published weekly data on the number of adult care homes that had reported at least one case of suspected or probable COVID-19 to the Care Inspectorate. Care Inspectorate Wales did not publish figures but these were available on request, while the Department for Health, Northern Ireland provided weekly updates on the number of outbreaks of suspected or confirmed COVID-19 cases in care homes, alongside the total number of care homes with closed cases.
How has COVID-19 affected residents’ mental health and wellbeing?
1. UK summary
Before the pandemic, care home residents were typically offered a range of activities aimed at maintaining their wellbeing, including trips to local attractions as well as activities led by outside providers and visits from family and friends. But all these things stopped abruptly from March 2020 as care homes put infection-control measures in place to protect residents’ health. Relatives and friends were told to stay away, and in many homes, residents were required to remain in their rooms, severely limiting contact with each other and with staff. ‘Purposeful rounding’ was implemented in many care homes, meaning that residents were only visited in their rooms by staff when carrying out essential tasks such as personal care, meals and medication.
Since then, care home residents have faced the loss of friends and associated bans from attending funerals, the fear of contracting COVID-19, and the new normality of staff wearing face coverings (there have been widespread reports of residents saying they miss seeing smiling faces). Anecdotal reports suggest the mood in care homes has been low, with residents often displaying distress and suffering negative emotions also associated with boredom from spending long periods alone in their bedrooms.
In an interview for this article, Jacqui Croxford, Compliance And Care Strategy Manager for Darbyshire Care, highlighted the difficulty of keeping people isolated even as the threat of COVID-19 starts to ease: ‘We can start letting residents out of their rooms, but then if a resident or staff member tests positive for COVID-19, everyone has to return to their rooms and isolate for another 14 days.’ She added that the frequency of isolation periods was taking its toll on the mental health of all residents – but particularly those without a cognitive impairment, who ‘are now really feeling the effects of loneliness and isolation’.
2. The impact of visiting restrictions
It is clear the restriction of visitors attending care home residents has had a number of detrimental effects, with widespread concerns expressed about the impact on residents’ mental health – both those with a cognitive impairment and those without. John’s Campaign and the Alzheimer’s Society have both highlighted the need for family members to continue supporting people with dementia in care homes.
Recognising the importance of contact with relatives, some care home staff have attempted to keep residents connected by organising window visits, whereby residents and relatives could see each other through closed windows. The BBC also reported on a Devon care home which organised ‘drive-by visits’, with residents being brought out of the care home to the roadside and relatives talking to them in safety from their cars.
The use of video calls to connect residents with their loved ones has, in some cases, been hampered by care homes’ poor or limited internet connections. Anecdotally, some staff have also reported that this method of communication can be difficult for residents who have poor eyesight, hearing problems and/or a cognitive impairment.
Recently, the UK government issued new guidance acknowledging visiting as a central part of care home life. As part of the lifting of lockdown restrictions, care home residents in England were allowed face-to-face visits from a single named visitor from 8 March 2021, provided the visitor passed a lateral flow test and wore PPE provided by the home. However, the Head of Dementia Care & Wellbeing of one for-profit organisation commented that information received from Public Health England has differed from region to region. Registered managers of care homes have the final say as to whether and when they open up to visitors.
3. A global snapshot of COVID-19 impacts
With many countries abruptly changing their care practices, increasing infection control measures and restricting visits to care homes to prevent COVID-19 outbreaks, anecdotal reports of cognitive decline and low mood have been plentiful. For example:
- A study conducted in the US reported that volunteer students providing telephone outreach to residents found they experienced restlessness and anxiety during the isolation period. It is important to note, however, they also reported this as an issue prior to COVID-19.
- One Dutch study reported high levels of loneliness and depression and worsening behavioural problems among care home residents during lockdown, with those residents without a cognitive impairment being particularly affected.
- While there is a lack of evidence that relatives are at higher risk of infection control than staff, there is accumulating evidence that visitor bans have severely impacted the mood of residents. A population-based study in Ontario found significant increases in psychotropic medication use for care home residents at the onset of the COVID-19 pandemic, which continued through September 2020.
Policy responses supporting the mental health of residents
1. Within the UK
To help keep residents in contact with their family and friends while ‘reducing unnecessary visits’ (and also to enable consultations with medical professionals), in September 2020 the Secretary of State for Health and Social Care, Matt Hancock, promised to deliver 11,000 free iPad tablets to care homes across England. This was followed in November by the Scottish Government announcing a £1m fund to provide around 1,400 care homes with up to two iPads each. Interviews with care home staff suggest this initiative was welcomed, although some identified issues around increased workload for staff, and problems with internet connections and battery life.
The Welsh Government produced an action plan for supporting care homes through the lockdown restrictions of winter 2020-21. The section for residents’ wellbeing included two items: ensuring care home residents would have the opportunity to share their experiences of living in care homes during the pandemic (target date: March 2021), and ensuring care home residents are supported to maintain contact with family and friends.
In Northern Ireland, guidance was issued in September 2020 by the Department of Health that care homes should move towards a Care Partner Scheme by November, which would enable one family member to go into a care home setting wearing PPE. However, the fact that visits were only happening in a small number of care homes led to a protest by families of some care residents outside the Stormont parliament building in late November.
It should also be noted that, while each government has provided guidance relating to visitors in care homes, some care home providers have used social media to vent their frustrations at the lack of timeliness and ambiguity of this guidance.
2. Rest of the world
Following the first period of lockdown, the Netherlands was one of the first countries to highlight the added value to residents’ wellbeing of real and personal contact. In response, guidelines were developed and a month-long study conducted last May to explore the possibility of (cautiously) re-opening nursing homes for visitors. The results highlighted the mental health benefits of family visits, and as a result, the Dutch government decided to allow all nursing homes to re-open according to their strict guidelines.
In January 2021, Low et al’s global evidence review on safe visiting in care homes recommended that blanket bans should not be used to prevent COVID-19 infection in care homes, and that family caregivers should be designated as ‘essential partners’ in residents’ care plans. At a recent LTC Covid webinar, some academics from Nordic countries noted that care home restrictions had negatively impacted the wellbeing of residents – in Iceland, the full restriction placed on care homes during the first lockdown was relaxed in the second due to concerns over the mental health and wellbeing of residents. Describing this shift in approach, the speaker recalled the words of one resident: ‘I would rather die from the plague than from loneliness.’
The impact of COVID-19 on UK care home staff
While research exists in relation to the mental health of nursing staff who have attended traumatic events such as Hurricane Katrina and who worked through the SARS epidemic, surprisingly little is known about the mental health and wellbeing of care home staff in the UK. Many care home staff build relationships with residents over long periods of time, and it is not unusual to hear them described as ‘family’.
Although staff have experience of providing end-of-life care to residents, doing so in the context of the rapid deterioration experienced by many people with COVID-19 – and dealing with increased caseloads while facing their own fears of contracting the virus – is likely to have had significant impacts on the mental health of care home staff.
The emergence of COVID-19 saw an unprecedented increase in the volume and intensity of work for care home staff – and rapid and frequent changes in care practices. Anecdotal reports suggest they have shown extreme levels of resilience and a dedicated attitude, with some staff moving into care homes to reduce the risk of infection – leading to round-the-clock working. But many staff report feeling overwhelmed and frustrated, with widespread concerns being expressed on social media at the speed in which care home managers have had to accommodate new protocols, and the way new guidance has been published.
A rapid review by Comas-Herrera et al of global evidence on the impacts of visiting policies in care homes during the pandemic found that visitor bans have been a ‘likely contributor to increases in staff workload, stress and burnout’, as prior to COVID-19, regular family visitors provided some essential care to their relatives. The review added that once lockdown ends, managing safe visits, increased infection control procedures and staff shortages are likely to add to the burden on staff.
Initiatives to support care home staff
In response to the challenges facing care home staff, some (but by no means all) UK care organisations introduced psychological assistance mechanisms such as telephone lines providing access to mental health support teams. Of those who did provide this assistance, it is anecdotally reported that some were unsure of its usefulness, with one care home manager noting that staff found it a ‘short-term’ measure and not particularly useful. A study by Maben and Bridges looking at existing research on the mental health of nursing staff working in crisis situations suggested that implementing psychological interventions while in the midst of a pandemic may sometimes do more harm than good.
Members of senior leadership teams reported to this author that, while lots of online help has been made available during the pandemic, sifting through what may or may not be useful is a job in itself that risks adding to their feeling of being overwhelmed. A senior manager of a care provider in England noted how underprepared they were in dealing with the elevated emotions of staff.
During the pandemic, the charity My Home Life launched ‘Conversations with Care Homes’ – a YouTube video series that aims to give care home staff a voice as well as sharing practice ideas. Key themes that have been identified include: feelings of isolation among staff; challenges with social distancing, particularly when people have a cognitive impairment; staff morale; and a lack of PPE. A WhatsApp group for care home staff was also set up to share ideas and ask questions.
This author’s own study, conducted during the pandemic, suggests care home staff have found that non-COVID-related training courses can boost their morale and make them feel more valued. The programme encouraged staff to think about everyday tasks that residents could do for themselves: from making their own bed and polishing possessions to doing their own hair. Responses suggest this not only enhanced the mental health of staff but lifted residents’ moods too – a finding that may prove useful beyond the immediate ‘COVID-19 period’.
It is clear that many lessons must be learnt from COVID-19 in relation to the UK social care system. It is important to focus on priorities that tackle the more deeply embedded issues that social care faces.
With regard to considerations of the mental health of care home residents, a priority is to explore how we measure quality-of-life for people living in care homes – in particular, those who have a cognitive impairment. Survey methods are a relatively inexpensive way of collecting large datasets quickly, but can be problematic for people with dementia who may, depending on their individual impairments, lack the ability to share their views through a written survey. Rather than relying on direct patient reports or ratings through interviews or written surveys, observer-based methods may be more inclusive because, beyond establishing consent to take part, participation is not reliant on cognitive ability.
As highlighted at the start of this article, a further priority must be to establish a more systematic approach to developing care home datasets, in order to exploit their full potential to enhance residents’ care and wellbeing. Current work in this area includes the ongoing DACHA study (Developing resources And minimum data set for Care Homes’ Adoption). The study, led by Professor Claire Goodman, aims to review how current health and social care systems work, explore how best to integrate the data, and test what a minimum dataset should look like if it is to be used as a key resource for all who work in and for care homes.
According to Burton et al, COVID-19 has provided impetus for addressing the UK’s care data gap. They conclude: ‘There is a critical need to understand the individual linked data sources and the context in which they have been collected. More effective utilisation and co-ordination of this data would be transformative in understanding the needs of this complex population.’
Finally, it is important to note that the mental health and wellbeing of care home residents is closely linked to that of the staff who care for them. There has been a clear difference in the value placed on NHS workers compared with social care staff during the pandemic (from ‘clapping for the NHS’ to preferential consumer services to levels of criticism in the media). For care home staff to thrive, we must ensure that the work they do is properly valued – from investing in their training and support, to recognising that care home environments are a complex space in which both medical and psychological care takes place.