Evidence to the Joint Committee on Human Rights inquiry on the Government’s response to Covid-19: human rights implications

Older people in residential social care

Friday 24 July 2020


Introduction

  1. The Equality and Human Rights Commission has been given powers by Parliament to advise Government on the equality and human rights implications of laws and proposed laws, and to publish information or provide advice, including to Parliament, on any matter related to equality, diversity and human rights.

Summary

  1. The coronavirus pandemic has profoundly affected many older people’s lives and raised serious questions about how our society values their rights. This submission focuses on older people who live in residential social care in England.[1] Around 400,000 older people live in these settings, many of whom are also disabled.[2]
  2. The impact on care homes has been devastating, with significant loss of life and a serious detrimental effect on older people’s health and wellbeing. The pandemic has highlighted long-standing pressures on the social care sector and its workforce, who have faced extremely challenging conditions and disproportionate exposure to the virus. Social care still does not have parity with health, despite commitments to reform over a number of years.
  3. It is critical that the Government continues to learn lessons from the pandemic and ensures the rights of older people are properly considered and protected. A rights-based approach will be crucial in planning for a possible second wave, in the broader coronavirus recovery strategy, and in delivering meaningful social care reform for the long term.

Recommendations

(1)               The Government should urgently undertake or commission a review into deaths in care homes during the pandemic, in line with its equality and human rights obligations.[3] This should include the impact of policies on hospital discharge, care home admissions, testing and PPE, the causes of ‘excess’ deaths in this period, regional variations in how care homes have been affected and the differential impact on groups sharing protected characteristics. Older people, their relatives and representative bodies must be meaningfully consulted and engaged in establishing and directing the review. The findings should be used on an ongoing basis to identify and implement changes in policy and practice to ensure older people’s rights are protected, both in the immediate term and in preparing for a potential second wave.

(2)               The Government should continue to take urgent steps to ensure that decisions about the health and care of older people in residential settings - both in individual cases and at the national policy level - are made in collaboration and consultation with older people and their representative organisations, and are supported by clear, accessible and consistent guidance that fully complies with human rights standards, including the principles of individual autonomy and non-discrimination.

(3)               The Government should assess whether restraint[4] has increased during the pandemic and work with providers, NHS Digital and the CQC to identify what additional support should be made available to avoid its use and ensure transparency and effective monitoring and oversight. Guidance on avoiding the use of restraint should build on existing resources and good practice and reflect the principles set out in the Commission’s human rights framework for restraint. Particular consideration should be given to groups who have impairments or characteristics that increase the risk of harm.

(4)               The CQC should ensure effective and ongoing oversight for care homes during the pandemic, expand inspections as far as possible with priority to those institutions where standards are most at risk (as informed by previous inspections and local intelligence gathering), and reinstate full inspections as soon as it is safe to do so. The CQC should further consider whether any immediate steps are required beyond existing routes to ensure that residents, relatives and staff can report concerns while outside visits are restricted.

(5)               The Government should amend guidance on care home visits to prohibit blanket restrictions and ensure all decisions are based on individual risk assessments. The guidance should be kept under review and updated to allow further relaxations to visiting policies where it is safe to do so. The Government must ensure there are mitigations in place so that care home residents can maintain contact with their loved ones in the case of further national or local lockdowns.

(6)               The Government should take immediate steps to investigate and address the reasons for the drop in applications for deprivation of liberty safeguards (DoLS) and work with providers to ensure older people who lack capacity can access independent advocacy. The Government should remind care home providers that the requirement to apply for DoLS remains in place where a deprivation of liberty is strictly necessary and the individual cannot consent to restrictions. Planned reforms to DoLS should be brought forward as soon as possible, and should emphasise supporting people to make decisions about their own care and treatment as far as possible.

(7)               The Government should bring forward proposals for the long-term reform of social care as soon as possible, including residential and community-based care for older people and disabled people of all ages. Proposals for reform must be informed by human rights principles including dignity, respect and equality, backed by sufficient resources and developed in close consultation with older people, disabled people, care providers and representative organisations, and with recognition of disabled people’s right to live independently.

A. The right to life

  1. The Government has positive obligations to protect life, including preventing avoidable deaths.[5] This right must be maintained even in times of emergency[6] and everyone has an equal right to protection.[7] The European Committee for the Prevention of Torture has stated that older people’s exposure to coronavirus and “extreme level of suffering” may be found incompatible with these obligations.[8]
  2. There were more than 18,500 deaths involving COVID-19 up to 12 June, accounting for almost 40 per cent of all deaths related to the virus.[9] Overall, there were 57,588 deaths in care homes during this period, which represents approximately 26,230 ‘excess’ deaths compared with previous years.[10] The COVID-19 mortality rate for care home residents was significantly higher than for other people of the same age[11] and data indicates a disproportionate impact on those from ethnic minorities.[12] Almost half of all care home deaths involving COVID-19 were of people with dementia and Alzheimer’s disease.[13]
  3. Decisions about hospital discharge,[14] testing[15] and supply of personal protective equipment (PPE)[16] may have contributed to this outcome and potentially discriminated against older people, contrary to human rights standards and the Equality Act 2010.[17] While we recognise that additional measures have been implemented as the pandemic progressed, we remain concerned that these issues present ongoing risks to older people’s fundamental rights.[18] Guidance continues to allow patients who have tested positive for COVID-19 to be admitted to care homes.[19]
  4. Understanding how decisions affect older people is crucial to prevent human rights breaches and to identify and mitigate any disproportionate impacts, as required by the public sector equality duty. Deaths from COVID-19 in care homes were not included in official reports until 29 April.[20] These reports do not include ethnicity, and there is generally a lack of ethnicity data across the sector.[21] There are also regional differences in how care homes have been affected, ranging from 28 per cent reporting outbreaks in the South West of England to 51 per cent in the North East,[22] which requires explanation.
  5. The Government should urgently undertake or commission a review into deaths in care homes during the pandemic, in line with its equality and human rights obligations.[23] This should include the impact of policies on hospital discharge, care home admissions, testing and PPE, the causes of ‘excess’ deaths in this period, regional variations in how care homes have been affected and the differential impact on groups sharing protected characteristics. Older people, their relatives and representative bodies must be meaningfully consulted and engaged in establishing and directing the review. The findings should be used on an ongoing basis to identify and implement changes in policy and practice to ensure older people’s rights are protected, both in the immediate term and in preparing for a potential second wave.

B. The right to health

  1.           In addition to its obligation to protect life, the Government has a duty to ensure everyone receives the ‘highest attainable’ standard of physical and mental healthcare.[24] The European Committee for the Prevention of Torture has made clear in the context of COVID-19 that “an inadequate level of health care can lead rapidly to situations falling within the scope of the term ‘inhuman and degrading treatment’.”[25]
  2.           Severe pressure on care homes and reductions and restrictions in healthcare services[26] have led to a deterioration in older people’s health.[27] The British Geriatrics Society has warned of the “real risk” of physical deconditioning due to isolation,[28] and serious concerns have been raised about the impact on mental health.[29] For those with dementia, isolation can cause cognitive and other skills to deteriorate rapidly, including communication skills and the ability to recognise family members.[30]
  3.           Blanket and potentially unlawful decisions were reportedly made about the care available to older people during the pandemic. Core health services including GP visits were removed from care homes as part of the effort to prioritise health capacity and prevent transmission of COVID-19.[31] We were deeply concerned by reports that Do Not Attempt Resuscitation (DNAR) notices were applied to people’s advance care plans without proper consultation.[32] Age UK and others have reported that some older people were pressured to sign DNAR forms and felt their lives and wishes did not matter.[33] The Government has committed to issue new guidelines on DNAR notices following a legal challenge.[34]
  4.           Providers have expressed concern about unclear and conflicting guidance on how to keep people safe throughout the pandemic.[35] They have faced specific challenges to implementing social distancing, isolation and testing, including because of the particular distress these measures can cause to residents[36] and the practical barriers to implementing infection controls in the older buildings that care homes typically occupy. Evidence also suggests COVID-19 symptoms present differently in older people which may mean they are not identified and treated appropriately.[37]
  5.           The Government should continue to take urgent steps to ensure that decisions about the health and care of older people in residential settings - both in individual cases and at the national policy level - are made in collaboration and consultation with older people and their representative organisations, and are supported by clear, accessible and consistent guidance that fully complies with human rights standards, including the principles of individual autonomy and non-discrimination.

C. Freedom from ill-treatment

  1.           The pressure on care homes may increase the risk that older people are subject to restraint.[38] We define restraint broadly as any act carried out with the purpose of restricting an individual’s movement, liberty and/or freedom to act independently, including chemical, mechanical and physical forms of control, coercion and enforced isolation.[39] Restraint could amount to inhuman or degrading treatment,[40] violate the right to physical and psychological integrity,[41] or otherwise be unlawful if it is not proportionate in the situation and used as a last resort to prevent harm.[42] Restraint is more likely to amount to inhuman and degrading treatment when it is used on groups who are at particular risk of harm or abuse.[43]
  2.           The Government should assess whether restraint has increased during the pandemic and work with providers, NHS Digital and the CQC to identify what additional support should be made available to avoid its use and ensure transparency and effective monitoring and oversight. Guidance on avoiding the use of restraint should build on existing resources and good practice and reflect the principles set out in the Commission’s human rights framework for restraint. Particular consideration should be given to groups who have impairments or characteristics that increase the risk of harm.
  3.           The period of heightened risk to older people’s rights during the pandemic coincides with reduced independent oversight while the CQC has suspended routine visits[44] and visits from families and outside healthcare staff are restricted.[45] There have been some instances of standards falling unacceptably during the pandemic.[46] In one case inspectors found residents who were malnourished, dehydrated and insufficiently protected from the risk of poor care or abuse.[47]
  4.           We have engaged with CQC on the issue of closed cultures and welcome the introduction of new guidance for inspectors on identifying and challenging cultures that can lead to human rights breaches and other harms.[48] The guidance was issued in recognition of the fact that more services are effectively operating as closed environments during the pandemic. We also understand the CQC is working to improve the accessibility of routes for residents, relatives and staff to report concerns.
  5.           The CQC should ensure effective and ongoing oversight for care homes during the pandemic, expand inspections as far as possible with priority to those institutions where standards are most at risk (as informed by previous inspections and local intelligence gathering), and reinstate full inspections as soon as it is safe to do so. The CQC should further consider whether any immediate steps are required beyond existing routes to ensure that residents, relatives and staff can report concerns while outside visits are restricted.

D. The right to a private and family life

  1.           In our view, blanket restrictions on visits to care homes could unnecessarily restrict people’s right to a private and family life[49] and further limit their right to health. A group of charities has reported that restrictions on visits have caused “much suffering and deterioration of mental and physical health” among residents.[50] There are particular concerns for people with dementia, whose cognitive and other skills may deteriorate rapidly without regular engagement.[51]
  2.           The British Geriatrics Society’s good practice guide states that for most residents the risk of exposure to COVID-19 from visits will outweigh the benefits, but there may be a “strong welfare case” for allowing visits in some cases to help reduce people’s distress.[52] It advises that decisions should be made case-by-case and in consultation with residents and their families, and that efforts should be made to facilitate safe visits for example in gardens and outdoor spaces.[53] We welcome updated guidance from Government to providers on how to assess the relative risks of allowing and restricting visits, although it does not explicitly rule out blanket restrictions.[54]
  3.           The Government should amend guidance on care home visits to prohibit blanket restrictions and ensure all decisions are based on individual risk assessments. The guidance should be kept under review and updated to allow further relaxations to visiting policies where it is safe to do so. The Government must ensure there are mitigations in place so that care home residents can maintain contact with their loved ones in the case of further national or local lockdowns.

E. The right to liberty

  1.           A number of older people in care homes are subject to deprivation of liberty safeguards (DoLS), which provide a legal framework to protect the rights of people who do not have the relevant capacity to make decisions about their treatment and care.[55] The risks to health in care homes during this period and the measures introduced to prevent infection (particularly isolation but also social distancing and testing) may change considerations of whether someone is deprived of their liberty and what is in their best interests.[56] The Court of Protection has observed a “striking and troubling” drop in DoLS applications during the pandemic, raising concerns about whether older people’s right to liberty is being properly protected.[57] The Court has also identified a significant reduction in referrals to advocacy services.
  2.           The Government should take immediate steps to investigate and address the reasons for the drop in DoLS applications and work with providers to ensure older people who lack capacity can access independent advocacy. The Government should remind care home providers that the requirement to apply for DoLS remains in place where a deprivation of liberty is strictly necessary and the individual cannot consent to restrictions. Planned reforms to DoLS should be brought forward as soon as possible, and should emphasise supporting people to make decisions about their own care and treatment as far as possible.

F. The future of social care

  1.           The pandemic has exposed and exacerbated long-standing problems in the social care sector, particularly in relation to parity with healthcare, workforce issues and resourcing. These problems persist despite commitments to reform over a number of years.[58] The Government has committed in this Parliament to provide extra funding and “urgently seek cross-party consensus for much needed long-term reform”.[59]
  2.           As outlined in our submissions to the Committee,[60] the pandemic has had a particularly acute impact on older and disabled people in need of care and support. The social care workforce has also been particularly affected.  Social care workers (who are more likely to be women and from ethnic minorities)[61] have died at disproportionate rates compared with their NHS colleagues,[62] and could not access regular testing until mid-April.[63] There is evidence linking reliance on agency staff and lack of sick pay to outbreaks of COVID-19 in care homes.[64] Recent survey data suggests only 4 per cent of directors of adult social services are fully confident their budget will be sufficient to meet their statutory duties this year.[65]
  3.           The Government should bring forward proposals for the long-term reform of social care as soon as possible, including residential and community-based care for older people and disabled people of all ages. Proposals for reform must be informed by human rights principles including dignity, respect and equality, backed by sufficient resources and developed in close consultation with older people, disabled people, care providers and representative organisations, and with recognition of disabled people’s right to live independently.

Further information

The Equality and Human Rights Commission is a statutory body established under the Equality Act 2006. Find out more about the Commission’s work on our website.

For more information, please contact:

Policy lead:

Lorel Clafton

Lorel.Clafton@equalityhumanrights,com

020 7832 7800

 

 

12

[1] Our evidence relates to the UK Government and the impact on care homes in England (responsibility for social care is devolved in Wales and Scotland). A number of working age and younger disabled people also live in care homes or other long-term care facilities where the issues raised by the pandemic are likely to be similar. Our previous submission to the Committee covers the impact of coronavirus on social care in the community and on disabled people’s right to live independently, and our evidence to the Women and Equalities Committee covers the impact of the pandemic on older people more broadly.

[2] For example 70 per cent have dementia, 60 per cent have mental health problems and 75 per cent have hearing loss, see Age UK (2019), Later life in the United Kingdom 2019.

[3] We have also recommended in our evidence to the Women and Equalities Committee, in relation to the impact of the pandemic on disabled people, that the Government undertake or commission a review into the disproportionate deaths of disabled people, including deaths in care homes.

[4] We define restraint broadly as any act carried out with the purpose of restricting an individual’s movement, liberty and/or freedom to act independently, including chemical, mechanical and physical forms of control, coercion and enforced isolation.

[5] Articles 2 and 3 of the European Convention on Human Rights (ECHR), incorporated into domestic law by the Human Rights Act 1998.

[6] Council of Europe (2020), Respecting democracy, rule of law and human rights in the framework of the COVID-19 sanitary crisis, a toolkit for member states, pp4-5.

[7] Article 14 ECHR requires that all rights in the Convention are protected and applied without discrimination, including on the basis of age.

[8] Council of Europe (2020), Respecting democracy, rule of law and human rights in the framework of the COVID-19 sanitary crisis, a toolkit for member states, p5.

[9] ONS (2020), Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional), figure 2; and ONS (2020), Comparison of weekly death occurrences in England and Wales: up to week ending 26 June 2020, figure 1. There were reportedly 46,604 deaths involving COVID-19 in England up to 12 June, including 18,562 among care home residents (39.8 per cent). This includes care home residents who have died in care homes and in hospitals. The ONS definition of "deaths involving COVID-19" is those deaths that had COVID-19 mentioned anywhere on the death certificate, whether as an underlying cause or not.

[10] ONS (2020), Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional), figure 12. There were 57,588 deaths in care homes from 2 March to 12 June (including deaths related to COVID-19), compared with an average of 31,357 deaths each year for the same period from 2015 to 2019.

[11] Ibid, figure 8. For example, for men aged 65-74 in England the mortality rate in COVID-19 related deaths was 5,392.1 per 100,000 people for care home residents, compared with 133.1 per 100,000 people for non-care home residents. It is not clear to what extent the characteristics of the care home population, including prevalence of comorbidities and greater clinical frailty, explain these differences.

[12] CQC (2020), CQC publishes data on deaths in care settings broken down by ethnicity. While the vast majority of all reported deaths across adult social care were White people, the proportion of deaths in care homes due to confirmed or suspected COVID-19 was higher for Black people (54 per cent) and Asian people (49 per cent) compared to White people (44 per cent). Note that CQC and ONS use different recording methods and the data are not directly comparable.

[13] ONS (2020), Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional).

[14] See: NHS England and NHS Improvement (17 March 2020), Important and urgent – next steps on NHS response to COVID-19; NHS (19 March 2020), COVID-19 hospital discharge service requirements; and Department for Health and Social Care (16 April 2020), COVID-19: our action plan for adult social care.

[15] Testing capacity was not extended to care homes until mid-April and some providers have continued to raise concerns about delays and difficulty accessing tests, see eg National Care Association (2020), Covid 19 statement from the Board of National Care Association, and National Care Foundation (5 May 2020), NCF survey finds that only 22 per cent of social care workers have been able to access testing.

[16] Social care providers were expected to source their own PPE supplies, see National Audit Office (2020), Readying the NHS and adult social care in England for COVID-19. Care England has highlighted that PPE requirements extend to everyone who interacts with the care system and not just front-line staff, see Care England (2020), Questions arising out of the ‘Admission and Care of Residents during COVID-19 Incident in a Care Home’ guidance.

[17] Article 14 ECHR. The Equality Act 2010 prevents discrimination on the basis of age among the 9 protected characteristics.

[18] Providers have highlighted access to regular testing and PPE among the key issues they face, see Care Provider Alliance (2020), Targeted CPA survey, business continuity.

[19] Department for Health and Social Care (16 April 2020), COVID-19: our action plan for adult social care.

[20] The King’s Fund (2020), Deaths from Covid-19 (coronavirus): how are they counted and what do they show?.

[21] CQC (2020), CQC publishes data on deaths in care settings broken down by ethnicity.

[22] CQC (2020), Our data from COVID-19, insight issue 2.

[23] We have also recommended in our evidence to the Women and Equalities Committee, in relation to the impact of the pandemic on disabled people, that the Government undertake or commission a review into the disproportionate deaths of disabled people, including deaths in care homes.

[24] The right to health is recognised under article 12 of the International Covenant on Economic, Social and Cultural Rights.

[25] Council of Europe (2020), Respecting democracy, rule of law and human rights in the framework of the COVID-19 sanitary crisis, a toolkit for member states, footnote 17.

[26] NHS (2020), COVID-19 prioritisation within community health services. Current Government guidance advises that routine non-essential medical appointments should be postponed, see Admission and care of residents in a care home during COVID-19, version 2.

[27] See footnote 9. Experts suggest data on deaths directly attributed to COVID-19 underestimate the impact of the pandemic on care home residents. Indirect causes of deaths linked to the pandemic could include people not seeking or receiving medical care as a result of fear of infection, a concern not to burden the NHS, or lack of access to care that is normally provided. See Adelina Comas-Herrera and Jose-Luis Fernández (2020), Estimates of number of deaths of care home residents linked to the COVID-19 pandemic in England.

[28] British Geriatrics Society (2020), Managing the COVID-19 pandemic in care homes for older people.

[29] The Relatives & Residents Association reported that at least half of all calls to its helpline since the start of the pandemic involved concerns about the mental health of someone in a care home, see Relatives & Residents Association (2020), Urgent action needed to prevent mental health crisis in care homes. The risks to older people’s mental health has been recognised by the World Health Organisation, see WHO (2020), Infection prevention and control guidance for long-term care facilities in the context of COVID-19: interim guidance, 21 March 2020.

[30] Alzheimer’s Society (2020), Evidence to the Health and Social Care Committee on delivering core NHS and care services during the pandemic and beyond.

[31] See Health and Social Care Committee (2020), Oral evidence: delivering core NHS and care services during the pandemic and beyond, Q247.

[32] Age UK (2020), Age UK response to DNR forms during Covid-19 crisis.

[33] Ibid.

[34] See Independent, Coronavirus: Matt Hancock to take action on ‘do not resuscitate’ orders after growing concern on use of notices during Covid-19 crisis, 14 July 2020.

[35] See Care Provider Alliance (2020), Targeted CPA survey, business continuity. Care England has raised 25 questions about the Government’s guidance on COVID-19 and care homes, including discrepancies with other guidance. See Care England (2020), Questions arising out of the ‘Admission and care of residents during COVID-19 incident in a care home’ guidance.

[36] See Care England (2020), Questions arising out of the ‘Admission and care of residents during COVID-19 incident in a care home’ guidance, and Alzheimer’s Society (2020), Care homes ‘left to fend for themselves against coronavirus’, which reports that a number of care homes surveyed said there were particular challenges with people with dementia who could not retain information about social distancing. The British Geriatrics Society also notes that swab tests may be particularly distressing for residents with dementia, autism or learning disabilities, see British Geriatrics Society (2020), Managing the COVID-19 pandemic in care homes for older people.

[37] Neil SN Graham et al, SARS-CoV-2 infection, clinical features and outcome of COVID-19 in United Kingdom nursing homes. This study of 4 nursing homes in London found that as many as 22 of 72 residents with symptoms (31 per cent) had none of the typical symptoms.

[38] Government guidance on avoiding restraint in health and care settings was published in 2014 in recognition of the fact that restrictive interventions had not been used consistently only as a last resort, and had in some cases been used to inflict pain, humiliate or punish. See Department for Health (2014), Positive and proactive care: reducing the need for restrictive interventions.

[39] See Equality and Human Rights Commission (2019), Human rights framework for restraint. Segregation that amounts to solitary confinement (defined as 22 hours a day or longer without meaningful human contact) is contrary to human rights standards as established by the Mandela Rules.

[40] Article 3 ECHR. The Government’s obligations to prohibit ill-treatment covers both deliberate abuse and neglect.

[41] Article 8 ECHR.

[42] Equality and Human Rights Commission (2019), Human rights framework for restraint.

[43] Ibid.

[44] Routine inspections were suspended on 16 March 2020 and by 16 July 2020 had not yet resumed. CQC (2020), Routine inspections suspended in response to coronavirus outbreak. The CQC has continued in this period to take action, as deemed appropriate, where they are alerted to a concern. 

[45] Estimates suggest 97 per cent of care homes have been closed to visits, see ONS (2020), Deaths involving COVID-19 in the care sector, England and Wales: deaths occurring up to 12 June 2020 and registered up to 20 June 2020 (provisional).

[46] At least two care homes were inspected during the pandemic and rated inadequate, see CQC (2020), Whitway House inspection report and Temple Court Care Home inspection report.

[47] CQC (2020), Temple Court Care Home inspection report.

[48] CQC (2020), Identifying and responding to closed cultures.

[49] Article 8 ECHR.

[50] Alzheimer’s Society (2020), An open letter to the Government – allow family carers key worker status.

[51] Ibid.

[52] British Geriatrics Society (2020), Managing the COVID-19 pandemic in care homes for older people.

[53] Ibid.

[54] Department for Health and Social Care (2020), Update on policies for visiting arrangements in care homes.

[55] The right to liberty is protected under article 5 ECHR. DoLS require that decisions made on behalf of someone who lacks capacity are in their best interests and that any restrictions on their freedom are appropriate. Just over 216,000 DoLS applications were completed in 2018-19, see NHS Digital (2019), Mental Capacity Act 2005, Deprivation of Liberty Safeguards England, 2018-19.

[56] The CQC has made clear that safeguards remain in force during the pandemic, and that deprivations of liberty should be avoided unless absolutely necessary and proportionate to avoid harm in the individual case, see CQC (2020), Working within the Mental Capacity Act during the coronavirus pandemic.

[57] Judiciary of England and Wales, Correspondence from the Vice President of the Court of Protection dated 4 May 2020.

[58] See National Audit Office (2020), Readying the NHS and adult social care in England for COVID-19.

[59] Prime Minister’s Office (2019), Queen’s Speech December 2019 – background briefing notes.

[60] See also our previous submission to the Committee on the impact of coronavirus on social care in the community and on disabled people’s right to live independently. 

[61] According to the Women’s Budget Group, 83 per cent of social care workers are women and around 21 per cent come from ethnic minorities, see Women’s Budget Group (April 2020), Crises collide: women and Covid-19.

[62] ONS (2020), Coronavirus (COVID-19) related deaths by occupation, England and Wales: deaths registered between 9 March and 25 May 2020, figures 5 and 6. This group includes care workers and home carers.

[63] See National Audit (2020), Readying the NHS and adult social care in England for COVID-19, para 19. Testing for front-line health workers was made available at the end of March.

[64] ONS (2020), Impact of coronavirus in care homes in England: 26 May to 19 June 2020.

[65] Association of Directors of Adult Social Services (2020), Budget survey 2020.