Catholic Medical Quarterly Volume 71(1) February 2021

Faith in Medicine

Managing a Nursing Home during COVID-19

Photo of Boarbank HallIn 2012, long-standing ties of affection persuaded Elizabeth McConnell to return to Boarbank Hall as Director of Operations and Registered Manager of their Nursing Home. This move followed a career which had recently been focused on crisis management - the move to Boarbank appeared a more restful option. Elizabeth’s first management role after moving from nursing was in charge of a 60-bedded care home, with half the patients mentally infirm, in a very deprived area of Glasgow. Daily crises included windows smashed and bins set on fire by the local children, quite apart from poor inspection reports. One morning early on, Elizabeth arrived for work to find out that every single member of the day staff, including the older lady from the laundry, had been locked up by the police after over-enthusiastic celebrations on the previous night. Elizabeth was well equipped when her company promoted her to Project Manager, focusing on problem-shooting in all their homes. She was given one week to save a home in a dire state and about to be closed by the Care Inspectorate, and was often managing several homes simultaneously where permanent managers were absent. Once she had to deal with a major fire in a 120-bedded home, including the aftermath and the rehousing of all the patients. As she put it simply, ‘Crisis management logistics became very much part of my day’. What a blessing for Boarbank Hall, then, that Elizabeth was in charge as COVID-19 loomed. This article is closely based on her detailed personal account of the first nine months of the crisis. It makes salutary reading. Even for someone of Elizabeth’s immense experience, managing a small nursing home, with an excellent team of staff and the support of the Community, was a huge and frightening challenge. How demanding, then, must it have been for the average care home manager, who is inevitably far less well qualified to face such a crisis? It seems essential that we learn from the policy mistakes of recent months, and also provide adequate support for the unsung heroines and heroes who have responsibility for all our care homes.

Anticipating the crisis

In January 2020, as the world became aware that a virus was sweeping Asia, just as SARS and MERS had done, we all hoped in our hearts that it would fizzle out. Even during the month of January, it was evident as we watched events unfold that the risk to global health was serious. The rapid rate of infection was terrifying to watch, especially as these areas were already locked down.

The first known case in the UK was on the 31st January. From that date, I cancelled my February annual leave and started to prepare Boarbank to deal with an outbreak. Italy reported their first known case on the very same day.

In the absence of official advice, I read up on measures taken during the Spanish flu, and watched other countries. Wanting to be ahead of the game, I attempted to bulk buy essential PPE. Without guidance, it was difficult knowing what PPE to buy, so I judged what to look for from what I could see the Chinese wearing on the news. Unfortunately, all the PPE I ordered was seized at the German border and returned for use within Germany.

As the pandemic unfolded in February and early March, nursing homes in Italy, America and Spain were being badly affected. In Italy, staff in one home had abandoned the patients altogether: it sounded like a horror movie. I remember this time as one when real fear and panic was gripping my insides almost every second of every day, while my nights were sleepless or disturbed by nightmares. On February 25th 2020, the Government published a document which advised that it was unlikely that COVID-19 would enter care homes in the UK. This made little sense, as, I knew that care homes would be as vulnerable as any other part of society: our staff, however careful they were, had to go home to their families and shop, while some hospital appointments or outside people coming in for urgent work would be unavoidable.

Already in these early weeks the pattern was set for the next few months: the anxieties and uncertainties, the practical difficulties, and the lack of reliable support from the authorities.

Anxieties and concerns

Lying awake at night, I worried about protecting the patients, the staff and their families, and the Community; mingled with this was also fear for my own ageing parents. My ample experience in crisis management did not include managing a pandemic. Although I was surrounded by people whom I trust immensely, whose advice I would welcome in normal circumstances, I sometimes felt very lonely in making decisions. I was afraid that I was robbing people of their normal life, that everyone was depending on me; that if I failed or got it wrong, then people could lose their lives. At the same time, I wanted to take complete control, so that if I did make the wrong decision, no one else could be blamed. I frequently thought of the conversation I would need to have with relatives should one of our patients die of COVID-19, and the guilt and failure I would feel. On a daily basis I found myself visiting the grotto and asking for guidance and protection for everyone at Boarbank. I even found myself bargaining with Our Lady - but the details of the bargain will stay between us!

When final lockdown came on the 23rd March, I was relieved but also very anxious. We knew very little about this virus, but we did know that people could incubate it long before they showed symptoms; this makes it a silent killer in a nursing home. Everyday, I lived with the fear that today would be the day that the outbreak would start. We imagined that every cough, every little ailment - of staff as well as patients - might be a symptom of the virus. We acted on all of these, isolated people, and monitored everything.

Practical preparations

I was very aware of the importance of pushing ahead with preparation even if I wasn’t absolutely sure of the best thing to do. In the middle of February we began to take the temperatures of both staff and visitors on arrival at Boarbank, as well as ensuring that they washed and sanitised their hands prior to coming into contact with anyone in the home. We started to sanitise all mail and packages and isolate these before they were presented to the patients. We also introduced taking residents’ temperatures on a daily basis. I began to focus on being aware of what was going on around the world and especially in Europe, and on implementing what I could see them doing. I also started a local chat group with other local care home managers, advising them of the strategies we were putting into place. This group continues to communicate frequently, asking for advice or sharing helpful information.

We had to be inventive with our PPE, so instead of Hazmat suits we ordered plastic ponchos with hoods, long sleeve vets gloves, shower caps and plastic car seat covers, and we even made our own visors. It was essential to ensure that both staff and patients felt protected, and trusted that everything was being done to protect them. It is difficult to explain just how much emotional energy and fear was spent trying to source PPE. I knew it was the vital link in the chain to ensure we could protect everyone as much as we possibly could, and that people’s lives depended on us using the right PPE and using it correctly. One main element was missing: face masks. Eventually, we were extremely fortunate to receive a large donation of masks from Hong Kong, which enabled all staff to wear masks at all times; this played a very significant part in reducing the risk of transmission in Boarbank from early on in the pandemic.

My energy now was turned to preparing the team to face the pandemic and feel they were fully supported and confident to deal with a potential outbreak. Building on the trust that was already there between the staff, the Sisters and myself was so important to ensure we had the strength to face the unknown together. Early in March we commenced staff meetings and enabled the staff to talk through all aspects of the pandemic, and we also formed support and communication networks in the form of WhatsApp groups, held daily briefings at hand overs, and provided training in donning and doffing PPE. We also trained in verifying Covid-19 deaths. Preparing and training Sisters and other members of staff to undertake roles they normally do not do was also an essential part of the plan due to the fear that several members of staff could easily become sick at the same time or have to isolate. Involving and informing staff about all of the preparations was a vital part as they could see measures were being taken to protect everyone as well as to deal with all eventualities.

We also prepared patients to make decisions about End-of-Life Care, as well as ensuring we had the right medication in place to keep patients comfortable and pain-free if required. This was strange and uncomfortable. We prepare patients all the time for a good death, but with this virus we were so uncertain of what to expect, that we felt we could not prepare them or ourselves properly.

There was a lot of fear around: fear of taking it home to family members, fear for family members who may be vulnerable, fear of anything happening to our patients and fear of the unknown. We were all watching the news and we could see what had transpired in care homes across Europe. During this time, we held very open discussions about fears and the reality of what could potentially happen. This openness helped staff to identify their fears and put them into perspective. It was also important to acknowledge that some of our staff, many of whom have worked for Boarbank for well over thirty years, were either vulnerable themselves or were caring for vulnerable loved ones at home.

On the 10th March, someone locally died of COVID-19, while local cases were increasing rapidly. Although the Prioress and I had planned a later date for stopping visitors, to allow residents to say goodbye to their families for this unknown period, I decided to close the nursing home immediately to all visitors. I expected criticism from residents and relatives, but everyone was very understanding, appreciative and supportive of any actions being taken to protect the patients, staff and Community. We also stopped all the patients attending Church services with the Community; again this was a very lonely and difficult decision as I know how important people’s faith is to them. We also had to close the Guest House and Chapel to outside visitors for several months.

The impact of outside bodies

Throughout this period, care homes desperately needed clear guidance and support from healthcare authorities and political policy, but these were not forthcoming. The document of 25th February set the tone. A few more concrete examples can fill out the picture.

  • The official provision of face masks certainly would not have been enough if we had experienced an outbreak: the total number of masks delivered to Boarbank by the authorities was 300, while since lockdown began, we have used around 180 a week. Early on, after much searching, I eventually managed to persuade a company to sell me 30 very good masks that could be used for patients in the event of an outbreak. Then the gift of 2,000 masks arrived from Hong Kong, as an answer to some serious prayer. We were very aware that not everyone was as blessed as we were.
  • From the beginning, I waited for helpful guidance from the authorities. When it finally began to come, it was very sketchy. The little guidance that came from Public Health England often changed, sometimes even on the same day, when time and energy had been spent on implementing it, and within hours it had to be changed again. It was mainly about the types of masks staff should be wearing and when they should be wearing them - yet it was extremely difficult to obtain the right type of masks. It certainly seemed as if care homes were seen as less important than the NHS in the pandemic.
  • On 12th March, the Strategic Commission Group from the local authority emailed requesting clarification that the home had certain procedures in place, as well as asking if the home could look at increasing its capacity. The CQC also got in touch in these early days advising that if Boarbank could increase its capacity, the process of registration had been made easier as well as the cost waivered. I would have liked to have been able to respond to a national need. However, after careful consideration, I could not see how to do this without putting the existing patients, staff and community at risk. After all, we were blessed with the advantage of seeing what was happening in other parts of Europe and just how infectious and devastating this virus is when it enters care facilities.
  • The pharmacist from the Strategic Team phoned early on in the pandemic and asked for the number of patients for whom we held end-of-life drugs. Eventually I got him to admit why he was asking - for the purpose of redeploying the medication to other areas such as the NHS, a strategy that seemed very reckless. I refused him, fearing that our patients might not have the drugs they required when needed, but the conversation was far from amicable: he simply assumed that he would be given the information he demanded and that the care home would do as it was told, leaving our residents vulnerable. During this period, I was spending a lot of time and energy simply fighting for the rights of the Boarbank patients.
  • National guidelines appeared which stated that patients being discharged from hospital did not require to be tested before admission into a care home. I believed from the beginning that this would make the care homes very vulnerable indeed. I was strongly berated by the Sister of a ward obviously under pressure to get someone discharged, when I required the patient in question to be tested prior to discharge. She almost shouted down the telephone; ‘Whose guidelines are you following?’ My own, was my reply, as I did not agree with or trust anyone else’s. Through the stress of the situation, relationships that would normally be very amicable and supportive were turning horrible. (Several weeks after the incident with the Sister on the ward, I interviewed a new carer, who told me he had witnessed this conversation in the hospital, and it became one of the deciding factors for applying for the position in Boarbank.)

Supporting each other

Within the home, by contrast, where we have always had a very supportive and friendly team, an even greater team spirit was developing. Staff, residents and the Sisters formed an extended community, all in it together, all there for each other. We have laughed, clapped, cried, played, danced and sung together. We continue to face this pandemic, but we do so as one big extended family.

Boarbank is set within beautiful grounds, surrounded by magnificent views across Morecambe Bay. During lockdown, I frequently found solace here, noticing different parts of nature and enjoying it as a true gift through this time. I frequently found myself looking out over the bay and thinking, ‘Is this terrible thing really happening out there?’ Surrounded by such beauty, it was difficult to conceive the suffering that was hitting other homes in the area, just a couple of miles away. I could not imagine what those patients, families and staff were going through. Such thoughts helped me to focus and make me more determined to do everything within my being to keep COVID-19 out of Boarbank Hall.

One afternoon, I received a WhatsApp message saying that in one home in the region 40 people had died. On reading this I had the worst sickening feeling in my stomach I have ever felt in my life, and I found myself shedding tears for all of those involved. This was definitely the lowest and hardest point in lockdown for me. I could not imagine this happening to our beautiful patients at Boarbank, or the staff going through it. How would I be able to support them and their families? For the rest of that afternoon, I found it extremely difficult to concentrate and it took several days to come to terms with this. Dancing together was a great help.

Although I found it very hard not going home to my family in Scotland every weekend, and was anxious about my elderly parents, I was very fortunate in having three sisters who I knew were caring for their every need. My parents themselves agreed with me to go into lockdown very early, in order for me to come down to Boarbank and do the job I needed to do. Having the ability to see them on facetime was a great blessing. Daily video calls with my sister were immensely supportive - something to look forward to and someone with whom I could be totally myself.

Looking to the future

We are now through the summer months and hitting autumn with the fear of what the next few months will bring: the number of cases in this area, as well as around the country, is rising rapidly again. I still find myself becoming very frustrated with the apparent lack of insight into and concern for care homes on the part of the authorities. I recently found myself on Radio Cumbria disagreeing with the Local Authority, who still believe COVID-positive patients can be discharged safely into Nursing Homes, as long as there is a higher weekly fee!

We are again at a crisis point where another full lockdown looks inevitable due to cases rising throughout the UK and we do not know what the future holds. However, our instinct to remain committed to the job of keeping everyone safe is as strong now as it was in February and March. I can honestly say that I could not have asked for a more competent and committed team with whom to face a pandemic.

I remain very fearful of what could happen if COVID-19 enters Boarbank and how might it affect everyone. This leaves me questioning everything I do; the decisions I take have the potential to make a drastic difference to the lives of many people. We also have an added concern going into this phase of the pandemic: people’s mental health is very vulnerable. This affects not only patients but staff and relatives too, and it has become imperative to be very mindful and sensitive to this.

Thankfully, we now undergo weekly testing, and the authorities have also learnt from discharging COVID-positive patients into care homes; these factors, as well increased knowledge about the virus, will help to reduce the number of care home deaths and cases. We hope and pray for a successful vaccine.