Higher occupancy and fewer staff increased Covid-19 infections at one of the UK’s biggest private care home operators, according to a study that raises questions about the business model for old-age care in Britain.
There was a significant increase in infection in 179 Four Seasons Health Care homes that were almost or entirely full, compared with those that had as many as a quarter of their beds empty, researchers at University College London (UCL) found.
Higher resident-to-staff ratios at the private equity-owned chain were also linked to more infections – a finding which follows a Public Health England (PHE) study that found the virus was spread by temporary agency workers used to make up for low staff numbers.
Overall, a third of the chain’s 9,000 residents showed symptoms or tested positive, and close to 600 people died from confirmed or suspected Covid-19. The UCL study has not yet been peer-reviewed and notes that it should not be used to guide clinical practice before it has been evaluated.
Large chains of private care homes aim to keep occupancy levels close to 90% to maintain profits. But the study found that even small decreases in occupancy significantly reduced risk.
There was a 78% increase in the rate of confirmed Covid infections between Four Seasons homes that had 0.7 to 0.85 residents per room and those with 0.85 to 1 per room. A majority of Four Seasons residents – 6,139 – lived in the more densely populated conditions, compared with 1,549 in the less crowded.
“Higher staff to resident ratios and reduced occupancy are critically important to reducing the spread of infection,” concluded the study, which was funded by the government-backed Economic and Social Research Council.
More than 17,000 people have died from Covid-19 in UK care homes, almost a third of all coronavirus deaths. Care homes remain on high alert for a second wave of infection and, with occupancy dipping during the pandemic and staffing and equipment costs increasing, some are struggling financially.
The UCL study also found:
Two-thirds of the Four Seasons homes had confirmed or suspected Covid, which is higher than the government’s estimate of prevalence across the sector. PHE’s latest data suggests outbreaks in 44% of homes in England.
Not all the infected Four Seasons homes notified PHE, which, if repeated across other care operators, means local health protection teams may have been unaware of infections in a fifth of homes (approximately 4,000).
The death rate among people with confirmed infection was 36%, which is higher than in some other studies, including of four London nursing homes where the rate was 17% and of 623 care homes in Ontario Canada where it was 28%.
Larger care homes are more prone to infection, confirming an earlier study of homes in Lanarkshire that found outbreaks much more likely in bigger homes.
Informed speculation and anecdotal evidence have so far highlighted shortages of personal protective equipment (PPE), a lack of testing and the admission of infected hospital patients as significant to the Covid crisis in care homes. The UCL study for the first time shows staffing and occupancy are key infection risks.
“These organisational factors, linked to chronic underfunding of the care sector, are likely to facilitate the implementation of infection control procedures such as isolating or cohorting infected residents, staff training, and regular environmental deep cleaning,” it said.
“When staff care for fewer residents they also have reduced likelihood of spreading infection between residents. Higher staff-to-resident ratios may also decrease reliance on agency staff who may spread infection between long-term care facilities, and indicate better-resourced [homes].”
The shadow minister for public health, Alex Norris, said the increased level of transmission in more densely populated care homes “shows how important it was for quick action from the government during the earlier stages of the pandemic, and highlights how damaging their slow response … has been”.
The Department of Health and Social Care said it had made £3.7bn available to councils in England to address pressures on local services caused by the pandemic, with an additional £600m to improve infection control.
“We know that there is a need for a long-term solution for social care, and will bring forward a plan that puts the sector on a sustainable footing taking into account what we have learned from the global pandemic,” a spokesperson said.
Before the pandemic, the UCL researchers had been working with Four Seasons to understand patterns of antibiotic use and developed the relationship to investigate the characteristics of care homes that were seeing high numbers of cases.
A Four Seasons home in Glasgow, Burlington Court, was one of the first to be hit by a fatal outbreak when 13 people died in one week in April. Another 13 people died at the chain’s Guthrie House care home in Edinburgh.
Four Seasons is majority-owned by a US private equity firm after going into administration in 2019 having defaulted on a £500m debt. The debt was left after ownership by Terra Firma, a UK private equity firm operated by the financier Guy Hands.
In response to the study, Four Seasons said occupancy rates during the pandemic were not related to the business model but were affected by factors including regulatory guidance, staffing levels and local demand for care.
In terms of staffing, the study discovered a 10 percentage point increase in the bed-to-staff ratio was associated with a 23% rise in infection. The finding will raise concerns about the 120,000 vacancies in the care workforce, fuelled by widespread minimum-wage pay.
Jeremy Richardson, the chief executive of Four Seasons, said strict protocols on infectious diseases including barrier nursing and social distancing were implemented across the homes. He said the firm’s approach was adapted in line with updated government guidance and provided daily updates to care authorities. All homes had access to PPE and public health authorities were updated regularly.
“We have and always will staff our homes appropriately and safe staffing levels were maintained throughout the pandemic,” he said. “Where we had to use agency workers to maintain safe staffing levels, we insisted that those people work in one care home only.”
Asked about occupancy, he added: “Prior to the outbreak, occupancy in our homes was at approximately 88%. This occupancy rate is in line with the rest of the industry and consistent with occupancy levels in previous years.