Re-opening and re-building day care services: Where to start and planning for the future
Different starting points
Services will have different starting points when considering safely re-opening, with some not having reopened since March 2020, some being near fully reopened and others providing a reduced or limited service.
During lockdown there may have been changes to contracts, re-deployment of staff, or an increase in the use of technology and home-based one-to-one support. The preferences and needs of people with a learning disability and/or autism, older people or people with dementia, a mental health or other conditions, and those of their carers and families, may have changed.
New and creative ways of providing support have emerged which may provide opportunities to innovate and do things differently, alongside new challenges involved in safely resuming services whilst minimising the risk of infection from COVID-19.
It may well be that day centres will move to a more blended or hybrid approach, with some irreplaceable face to face elements being retained, while others being conducted remotely or virtually for those who are unable to access a building.
Although most people using and working in social care are now fully vaccinated, it is still possible to catch and spread COVID-19. It is recognised that older people and those with physical or learning disabilities may have more co-morbidities which are risk factors for worse outcomes should they become unwell with COVID-19. For their safety, and the safety of their families, the staff that support them and the general public, it is essential that resuming and rebuilding day services is approached with caution. Plans must be underpinned by continued UK Health Security Agency (UKHSA) guidance.
Day care offers an essential service and improves the quality of life for those that participate and for their carers. It is a central component of social citizenship for many. It is essential that participants and carers continue to receive the support they need. However, despite the ending of lockdown and restrictions people may continue to be anxious and worried about accessing public spaces and will need to be supported and reassured that it is safe to do so. At the same time, new ways of working and organising services may be needed to keep those who use services, their carers and families, staff and the general public at the lowest risk of infection.
Communication and engagement with people and carers accessing services
Clear, regular communication is essential and providers should develop a communication plan to ensure that all people using services and their families are kept informed of what which services have been resumed and what is likely to happen in the weeks and months ahead.
Consideration of how to support people to transition back into a service will be necessary. The current health crisis has increased confusion, fear and anxiety for everyone, and inevitably it will bring additional challenges. There may be a need for detailed planning where people will need to adjust to returning to a service, having adapted to new routines during lockdown, and where they are unsettled or even traumatised by change (potentially resulting in escalation of behaviours that challenge or unmet needs). Some people returning to face- to-face activities may have experienced a loss of confidence or be anxious about of getting back to 'normal' activities.
Conversations with people accessing day care services and their families should seek to ascertain their welfare and support needs. Planning should be person centred, but drawing on a whole family approach where carers’ needs are also recognised, including those of young adult carers. For some individuals, carers and families, multiple conversations may be needed and a great deal of flexibility in planning.
Any planning will need to be done within the context of the Mental Capacity Act, which affirms the right of people to make their own decisions where they are able. If a person has capacity to decide whether or not they wish to return to a day setting which is available to them, that decision must be respected. If a person chooses not to go, and that causes additional pressures for their family or carers, they cannot be forced to go. A negotiation will be needed.
If the person lacks capacity to make a decision about returning to day care, a best interests decision will need to be made. Using the best interests checklist (see the MCA Code of Practice, 5.13), a decision will need to be made - involving carers, families and professionals - about whether a return would be in the best interests of the individual. This would need to factor in the person’s past and present wishes, feelings and beliefs – the extent to which they enjoyed attending day care prior to the COVID-19 lockdown would need to be considered. Also consider a balance of risks between COVID-19 and the impacts perhaps of continued isolation.
It is important to note that the best interests of any family members - who may wish for someone to return to day care, in order to have a much-needed break or return to work - cannot be a determining factor in whether it is the person's best interests to go. But, this may affect the care being provided - in this case a carer's assessment could be appropriate.
Information that is useful to know:
- What services did they receive prior to lockdown? This includes services with all providers as some people use more than one.
- What support have they received since lockdown (if any)? How have they found that?
- What would they like support to look like going forward? It could be that they would prefer a continuation of current support, or return to group activities.
- If they have been accessing no services or different services since lockdown, what needs to be planned for the transition back? Are there challenges or key considerations? This could be a process for some, especially those for whom social situations and communication already posed a challenge.
- What is their level of need and/or risk? For example, pressures on carers, any deterioration in physical, cognitive or mental health or mobility.
- What understanding do they and/or their families have around keeping safe in the community and what are their concerns?
- Understanding that even though lockdown has lifted, services may not be able to return to pre-lockdown for the many providers and groups.
For those who would like to return to face-to-face services, the responsibilities of those using the services and their families should be addressed and could involve an agreement or checklist. Responsibilities include not using the service if they are unwell and following Government guidelines to the best of their ability. Where someone has not been able to follow guidelines, sharing this information with the provider is essential.
Conversations between commissioners and providers
Commissioners and providers have responded to the COVID-19 crisis in different ways with varying levels and forms of continued provision. Whatever the current status of the service, it is useful to have an open and reflective conversation. Principles for this conversation:
- What has been your 'journey' during lockdown and what, if any, services have been maintained, started or put on hold?
- What do services look like at the moment? What are the challenges? What helps?
- What might the longer-term future of the service look like and what are the unknowns for future planning?
Areas to consider within this conversation:
- Your values: What is the purpose of your service and how can those values be taken forward even if their delivery needs to change.
- Financial considerations: Including the existing model of funding and if/how that will work moving forward. The likelihood of additional costs due to recommendations and requirements around personal protective equipment (PPE) and infection prevention and control. Changes to the numbers of people accessing some forms of day care, and other forms of support in the context of the whole care package, needs and preferences of individuals. Consider the need for services to remain sustainable in the longer term.
- New ways of working and opportunities: Are there new and innovative ways of working and delivering services that have taken place during the COVID-19 crisis? Would it be of benefit to continue or expand these? What have been positive lessons learned? For those re-opening, what new ways of working can be developed that would benefit services in the longer term?
Considering other agencies and contractors (such as building landlords, public facilities, insurers and transport providers)
Depending on the service provided, a range of agencies and contractors may need to be involved in the safe re-opening or expansion of face-to-face services. This includes:
- Insurance providers: The Department of Health and Social Care (DHSC) has sought advice from experts within the insurance broking community. There is no suggestion that day and respite services would not continue to be covered by their existing insurance policies. Organisations are however encouraged to speak to their insurance providers, who can give advice on their individual policy.
- Building landlords and management groups: Ensure relevant health and safety checks have been undertaken for buildings that have been closed or new spaces that may now need to be used. Be clear who has responsibility for deep cleaning and regular cleaning. Make sure you are aware of any other users of the building, and know who is responsible for handing over and cleaning between user groups.
- Transport providers: For those relying on community transport, new contracts of working are likely to be needed.
Additional considerations for staff and volunteers
It is important to ensure that staff and volunteers feel safe and supported within the context of all service resumption planning and their concerns and needs are considered when re-opening or expanding face-to-face support. Staff that have been redeployed will need to have an agreed plan for returning to day services.
New protocols could introduce unfamiliar ways of working for staff and volunteers – this may be stressful and staff may feel more isolated. For example, increased online and telephone communication with families, wearing PPE, changed work patterns and alterations to typical activities.
A 'return to work' protocol for all staff and volunteers can reassure staff of the measures being taken to minimise risk of infection and of the support in place for them as they return.
COVID-19-specific training Open
Staff training is required regarding new ways of working and COVID-19 etiquette. It is important staff understand why new systems and protocols are in place and how they can help to minimise risk. This includes:
Support and wellbeing Open
As well as a risk assessment for staff and volunteers, their wider needs and wellbeing is important to consider. Important issues may include:
- feelings of isolation
- guilt at not being able to provide the same level of service as previously
- returning staff may feel like they are ‘starting a new job’
- exhaustion or burnout
- staff not having taken breaks or leave
- caring responsibilities
- changes in availability to work
- Long COVID
Staff may value the opportunity for discussion and reassurance, and appreciate having more than one method of communication available. Conversations about what has worked for them, and opportunities for formal and informal peer support are also helpful to social care staff.
Responding to bereavement and trauma
Many people have experienced bereavement trauma during the COVID-19 pandemic, including people who use services, families, staff and volunteers.
A key consideration will be on the impact of COVID-19 on anyone who may also be experiencing trauma as a result of the challenges of COVID-19 in their work, day care, home and personal lives.
Some resources that may help with supporting those with trauma or grief are: