Specific analytical support for the Social Protection Committee peer review meeting : Joint Initiative between the Ministry of Health and Social Care for Health monitoring of care homes in relation to the COVID-19 pandemic : (Online), 16 and 17 April 2024 : synthesis report.
Date: 2024-07-29
Institutions: Directorate-General for Employment, Social Affairs and Inclusion
Subjects: Bulgaria, Cyprus, Germany, Greece, action programme, antimicrobial resistance, audit, conference proceedings, continuing vocational training, coronavirus disease, disease surveillance, long-term care, mental health, social well-being, social-security benefit, standard

Social Protection Committee Online 
Peer Review: 
“Joint Initiative between the Ministry 
of Health and Social Care for health 
monitoring of care homes” 

Synthesis Report 

EMPL/2023/VLVP/0027 

Written by Lukas Becker & Charlotte Birnbaum 
May 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
2 

 
 
 
 
 
 
 
 
 
 
 
EUROPEAN COMMISSION 

Directorate-General for Employment, Social Affairs and Inclusion 
Directorate Jobs, Skills and Social Policies 
Unit EMPL.D.1 – Social Policies, Child Guarantee, SPC 

E-mail: empl-spsi-peer-reviews@ec.europa.eu

European Commission
B-1049 Brussels

The opinions expressed in this document are those of the authors only and should not be considered as representative of 
the European Commission’s official position.  

The European Commission is not liable for any consequence stemming from the reuse of this publication. 

2024 

Directorate-General for Employment, Social Affairs and Inclusion 

EN 

3 

Specific analytical support for the 
Social Protection Committee peer 
review meeting: Joint Initiative 
between the Ministry of Health and 
the Social Welfare Services of 
Cyprus for health monitoring of care 
homes in relation to the COVID-19 
pandemic 

Synthesis Report 

4 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Manuscript completed in May 2024. 

First edition 

This document should not be considered as representative of the European Commission’s official position.  

Luxembourg: Publications Office of the European Union, 2024. 

© European Union, 2024 
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ISBN 978-92-68-14304-9 

DOI: 10.2767/972317 

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2024  

Directorate-General for Employment, Social Affairs and Inclusion 

EN 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

Table of Contents 

1. 

Introduction ...................................................................................................... 7 

2.  Host country’s joint initiative for health monitoring of care homes in relation to 
the COVID-19 pandemic ....................................................................................... 11 

2.3.1 Continuous monitoring: epidemiological COVID-19 surveillance ..........................14 
2.3.2 Alignment of standard operating procedures for care homes ...............................14 
2.3.3 Intensification of audits in the care homes ...........................................................15 
2.3.4  Continuous  training,  communication,  and  feedback  to  the  managers  of  the  care 
homes...........................................................................................................................15 

3.  Peer country approaches ............................................................................... 16 

3.1.1 Background information .......................................................................................16 
3.1.2 Action plan at district and municipal level for integrated health and social services 
for residential care ........................................................................................................17 
3.2.1. Background on the German LTC Sector .............................................................17 
3.2.2. Action Plan Autumn/Winter 2022/23 (“Herbstkonzept”)  ......................................18 
3.3.1 Background on Greek government action on healthcare-associated infections and 
antibiotic-resistant pathogens .......................................................................................18 
3.3.2 Greek action plan .................................................................................................19 

4.  Discussion points and key learnings .............................................................. 19 

4.2.1 Permanent advisory institutions ...........................................................................20 
4.2.2 Guidance and support for care providers .............................................................21 
4.2.3 Bottom-up coordination between relevant authorities and stakeholders ...............22 

5.  Conclusion ..................................................................................................... 23 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

1. 

Introduction 

The focus of this Peer Review was on monitoring of health and well-being of residents in LTC 
homes.  Drawing  on  experiences  and  lessons  learned  during  the  COVID-19  pandemic,  the 
Cypriot Ministry of Health (MoH) and the Cypriot Deputy Ministry of Social Welfare (DMSW) 
presented their Joint Initiative between the Ministry of Health and Social Welfare Services of 
Cyprus for health monitoring of care homes in relation to the COVID-19 pandemic; this was 
the  starting  point  for  discussions  about  approaches  to  prevention  and  control  measures  of 
infectious diseases in long-term care (LTC) facilities during and after the pandemic.  

The  pandemic  shed  light  on  the  lack  of  adequate  protocols  and  measures  to  manage 
disease  outbreaks  and  revealed  that  institutions,  such  as  care  facilities,  were  insufficiently 
prepared  to  manage  the  outbreak  of  COVID-19.  Due  to  the  lack  of  overarching  guidelines 
and  outdated  legal  and  regulatory  frameworks,  care  home  managers  and  professionals  in 
Cyprus  developed  bottom-up  coordinated  policies  which  resulted  in  the  establishment  of 
innovative practices and the refinement of existing protocols.  

In the spirit of peer learning and exchanges among EU countries through the Open Method 
of  Coordination,  the  Social  Protection  Committee  invited  representatives  from  Cyprus, 
Bulgaria, Germany and Greece to discuss:   

- 

the  monitoring  of  health  and  well-being  in  residential  care  settings  in  the  event  of 
disease outbreaks  

- 

forward-looking policies integrating social and health care approaches, and 

-  approaches to improve LTC and the well-being of care residents more broadly. 

The  Peer  Review  meeting  was  hosted  by  the  Cypriot  Ministry  of  Health’s  (MoH)  and  the 
Cypriot Deputy Ministry of Social Welfare (DMSW) and took place online on the 16 - 17 April 
2024.  The  meeting  brought  together  representatives  from  the  Ministry  of  Health  and  the 
Cabinet  of  the  Secretary  General  for  Social  Solidarity  and  the  Fight  Against  Poverty  from 
Greece,  the  Federal  Ministry  of  Health  from  Germany,  the  Bulgarian  Agency  for  Social 
Assistance  Programming  and  the  Sofia  Regional  Health  Inspectorate,  as  well  as  the 
Bulgarian NGOs Global Initiative on Psychiatry and the Institute for Community-based Social 
Services. 

1.1  EU context 

The  EU  faces  structural  and  demographic  challenges  as  the  general  population  ages:  a 
decline in functional ability typically associated with ageing will exacerbate preexisting issues 
and  stretch  limited  capacities  in  the  LTC  sector  in  EU  Member  States1.  The  COVID-19 
pandemic  amplified  these  structural  issues  (i.e.  insufficient  funding,  lack  of  personnel, 
unattractive  working  conditions,  insufficient  personal  protective  equipment,  supplies  and 
resources,  etc.)  and  presented  practical  and  ethical  dilemmas  in  dealing  with  the  high 
mortality  rates.  Containment  measures  were  introduced  to  alleviate  the  pressure  on 
healthcare  systems,  given  their  overstretched  capacities2.  Existing  policies  and  emergency 

1 Council Of The European Union, Council Recommendation of 8 December 2022 on access to affordable high-quality long-term 
care 2022/C 476/01, accessed at: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32022H1215(01) 
(24.04.2024) 
2 Verelst, F., Kuylen, E., & Beutels, P. (2020). Indications for healthcare surge capacity in European countries facing an 
exponential increase in coronavirus disease (COVID-19) cases, March 2020. Euro surveillance : bulletin Europeen sur les 
maladies transmissibles = European communicable disease bulletin, 25(13), 2000323, accessed at : 
https://doi.org/10.2807/1560-7917.ES.2020.25.13.2000323 (03.05.2024) 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

protocols were insufficient to respond to the catastrophic effects of the pandemic and led to a 
reckoning  on  the  limitations  of  pandemic  preparedness  and  response  measures  developed 
on the basis of medically-driven considerations. In fact, beyond the repercussions witnessed 
from  a  medical  point  of  view,  effects  on  the  populations’  well-being  were  mostly  neglected 
when  implementing  measures  such  as  social  distancing  and  isolation  of  infected  and 
vulnerable persons and discontinuation of activities crucial for people’s day-to-day lives.  

In LTC settings, high mortality and large outbreaks of COVID-19 revealed the need for a new 
quality  assurance  approach  to  monitor  hygiene  and  health  compliance  in  such  settings. 
However,  the  measures  taken  to  protect  care  residents,  such  as  quarantine  and  social 
distancing,  also  had  a  profound  impact  on  the  mental  and  physical  well-being  of  residents 
(and their families)  3. Ethical questions as to whether personal safety takes precedence over 
personal  quality  of  life  arose  when  shifting  the  focus  from  medical  safety  to  including  other 
health and well-being drivers (e.g. mental health).  

While these questions are not new within LTC settings, discussions around the priorities and 
expectations  of  LTC  are  ongoing.  The  shift  from  personal  safety  to  well-being,  person-
centred  and  human-rights-based  approaches  invites  reconsideration  as  to  what  adequate, 
affordable, high-quality LTC implies, especially in view of increased demand projections. Key 
prerequisites  for  quality  LTC  primarily  depend  on  effective  quality  assurance  mechanisms, 
which  are  often  lacking  or  under-resourced4,  as  exemplified  by  the  Cypriot  context  and  the 
shortage of trained staff.  

Even before the COVID-19 pandemic hit, the European Commission began to consider the 
implications of European ageing societies, also in terms of LTC5, feeding into the European 
Pillar of Social Rights6 and the correspoding Action Plan7.  

Alongside  the  protection  of  those  who  are  cared  for  (addressed  by  Principle  18),  the 
European Pillar of Social Rights also highlights in Principle 98: 

- 

 the  right  of  people  with  caring  responsbilities  to  suitable  leave,  flexible  working 
arrangements and access to care services; 

3 McGarrigle, L., Todd. Chris (dd) The adverse effects of social isolation and loneliness on psychological and physical health 
outcomes in care home residents during Covid-19, accessed 
at:https://assets.publishing.service.gov.uk/media/611e8334d3bf7f63b086cb41/S0584_Adverse_effects_of_social_isolation_and
_loneliness_in_care_homes_during_COVID-19.pdf (03.05.2024) 
4 Council Of The European Union, Council Recommendation of 8 December 2022 on access to affordable high-quality long-term 
care 2022/C 476/01, accessed at: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32022H1215(01) 
(24.04.2024) 

5 European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, 
challenges and opportunities in an ageing society. Volume I, Publications Office, 2021, accessed at: 
https://data.europa.eu/doi/10.2767/677726 (24.04.2024) 

6 European Commission, Commission Recommendation (EU) 2017/761 of 26 April 2017 on the European Pillar of Social Rights, 
Official Journal of the European Union, 113 (29), 2017, p.56-61. Accessed at: https://eur-lex.europa.eu/legal-
content/EN/TXT/PDF/?uri=CELEX:32017H0761. (3.05.2024) 

7 European Commission, Directorate-General for Employment, Social Affairs and Inclusion, The European Pillar of Social Rights 
Action Plan, accessed at: https://eur-lex.europa.eu/legal-
content/EN/TXT/?uri=COM%3A2021%3A102%3AFIN&qid=1614928358298#PP1Contents (30.04.2024) 

8European Commission, Commission Recommendation (EU) 2017/761 of 26 April 2017 on the European Pillar of Social Rights, 
Official Journal of the European Union, 113 (29), 2017, p.56-61. Accessed at: https://eur-lex.europa.eu/legal-
content/EN/TXT/PDF/?uri=CELEX:32017H0761. (3.05.2024) 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

- 

the  right  of  women  and  men  to  have  equal  access  to  special  leaves  of  absence  in 
order  to  fulfil  their  caring  responsibilities,  while  being  encouraged  to  use  them  in  a 
balanced way.  

The  Commission  proposed  common  LTC  quality  principles  in  a  Council  Recommendation9, 
which the Council of the European Union then adopted in December 20221011 (see Figure 1).  

Figure 1 Principles for long-term care in the Council Recommendation 

Source: Authors’ own elaboration based on Council Recommendation of 8 December 2022 (2022/C 476/01) 

The Council Recommendation highlights the need for an integrated person-centred approach 
with a concerted effort from all relevant actors in health and social care at EU, national and 
local  levels  to  develop  a  range  of  services,  such  as  home  care  and  community-based 
services,  to  ensure  that  those  in  need  of  LTC  can  access  the  care  they  need,  while  being  
included  in  society  and  that  the  quality  of  all  types  of  LTC  is  ensured.  The  European  care 
strategy12  also  talks  about  the  need  for  better  funding  and  the  tackling  of  workforce  issues 
and emphasises the  immediate requirement to enhance  the resilience of  LTC  systems  and 
increase  efforts  to  foster  personal  autonomy  and  independent  living  of  people  in  need  of 
care.  

9 Council Of The European Union, Council Recommendation of 8 December 2022 on access to affordable high-quality long-term 
care 2022/C 476/01, accessed at: https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32022H1215(01) 
(24.04.2024) 

10 European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, 
challenges and opportunities in an ageing society. Volume I, Publications Office, 2021, accessed at: 
https://data.europa.eu/doi/10.2767/677726 (24.04.2024) 

11Communication from the Commission to the European Parliament, the Council, the European Economic and Social Committee 
and the Committee of the Regions on the European care strategy. Accessed at :   
IMMC.COM%282022%29440%20final.ENG.xhtml.1_EN_ACT_part1_v12.docx (europa.eu) (24.04.2024). See also : A 
European Care Strategy for caregivers and care receivers - Employment, Social Affairs & Inclusion - European Commission 
(europa.eu)  

12 European Commission, A European Care Strategy for caregivers and care receivers, 2022. Accessed at: 
https://ec.europa.eu/commission/presscorner/detail/en/ip_22_5169 (3.05.2024) 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

1.2  Approaches to LTC in the Member States 

An increased demand for LTC will derive from the increasing lifespan of European citizens, 
challenging  already  stretched  capacities  of  LTC  facilities.  In  response  to  the  changing 
demographic  and  economic  structures  in  the  EU, Member  States,  have developed  different 
policy reforms in LTC to increase access, fiscal sustainability and quality of affordable care, 
publicly or privately provided.  

Member States’ modes of LTC provision varies, in terms of governance structure and level, 
degree of coverage, provision criteria and funding13. The governance structure takes the form 
of  an  “integrated”system,  when LTC  is  part  of the  broader  public social protection services, 
and of a “split” system, when LTC is split between healthcare and social care/assistance and 
between  institutions  in  charge  of  providing  cash  benefits  and  those  providing  in-kind 
services.  

Variations  are  also  found  at  the  levels  of  responsibilities  and  organisation  of  LTC (national, 
regional, local). In most EU Member States, LTC provision is a shared responsibility across 
governmental level, based on the service provided (healthcare, social care services or cash 
allowances). In the Nordic countries it is organised at the municipal level (DK, FI, SE), while 
in most of the Continental countries it is provided at the national level (AT, DE, LU, NL).  

While  all  Member  States  offer  services,  including  residential  or  semi-residential  care, 
different  home  care  and  other  in-kind  forms  of  support,  the  degree  of  coverage  of  these 
services differs across countries, with several Central and Eastern European Member States 
displaying  comparatively  lower  coverage,  especially  of  home  and  community-based 
services14.  

Another  key  differentiating  aspect  is  whether  LTC  is  provided  universally  (i.e.  publicly 
provided to all residents) or in a selective manner, whereby conditionalities apply to different 
population groups (needs-based or income-based). Selectivist and mixed models are mostly 
found  in  Central  Eastern  and  Southern  European  countries,  while  quasi-universalist  and 
universalist  systems  are  mostly  in  place  in  Continental  and  Northern  European  countries. 
Linked to LTC service provision is the financing, which can derive from taxation, compulsory 
social contributions, or from a mix of these.   

Considering  all  the  above  factors,  LTC  provision  relies  on  different  degrees  of  state 
intervention and varying degrees of capacity. Nonetheless, the main challenges that the LTC 
sector faces are largely common across EU Member States1516. These entail: 

-  Unmet LTC needs of many people; 

-  Quality of LTC; 

-  Difficulty in retaining and attracting formal (and trained) care workers; 

-  Struggles  encountered  by  informal  care  workers,  e.g.  insufficient  access  to  support 

measures or resources; 

13 Pavoloni, E. (2021), Long-term care social protection models in the EU, European Social Policy Network, Luxembourg: 
Publications Office of the European Union.  

14 Pavoloni, E. (2021), Long-term care social protection models in the EU, European Social Policy Network, Luxembourg: 
Publications Office of the European Union 

15 European Commission, Directorate-General for Employment, Social Affairs and Inclusion, Long-term care report – Trends, 
challenges and opportunities in an ageing society. Volume I, Publications Office, 2021, accessed at: 
https://data.europa.eu/doi/10.2767/677726 (24.04.2024) 

16 Spasova, S., Baeten, R., Vanhercke, B (2018) Challenges in long-term care in Europe, Eurohealth Observer, 24 (4). 
https://ec.europa.eu/social/main.jsp?catId=738&langId=en&pubId=8128&furtherPubs=yes 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

- 

Inequalities in accessing (quality) LTC; 

-  Gender  imbalance  within  the  care  workforce,  whereby  care  responsibilities  are 
overwhelmingly  attributed  to  women,  which  consequently  excludes  them  from  the 
labour market. At the same time, women are more likely to need LTC, but are not as 
likely to be able to access it; 

-  Financial sustainability, as LTC is the social expenditure increasing the fastest in the 

EU, projected to rise from 1.7% to 2.5% of GDP between 2019 and 2050. 

In light  of  differences in policy  measures  adopted across  EU Member  States  in confronting 
common  challenges,  the  Social  Protection  Committee’s  Open  Method  of  Coordination 
encourages  mutual  learning  processes  to  facilitate  exchanges,  peer  learning  and  capacity 
building regarding policy developments and reforms. The Ministry of Health of the Republic 
of  Cyprus,  in  collaboration  with  the  Deputy  Ministry  of  Social  Welfare,  embraced  the 
opportunity  to  gain  feedback  on  their  programme  to  improve  access  to  high-quality  care  in 
residential  settings  through  collaboration  between  health  and  social  services.  In  particular, 
the peer review discussions focused on: 

-  monitoring of infection rates in care homes (during and after COVID-19), 

- 

- 

strategies to ensure well-being through a wide array of activities,  

strengthening  collaboration  between  stakeholders  from  the  health  and  social  care 
sectors.  

The Cypriot MoH also sought to better understand how peer countries tackled the COVID-19 
pandemic  in  their  own  contexts.  The  aim  of  the  peer  review  was  to  ultimately  identify 
transferable aspects of participating countries’ practices and approaches, following in-depth 
discussions and critical reflections on strengths, weaknesses, threats, and opportunities that 
these provide.  

2.  Host  country’s  joint  initiative  for  health  monitoring  of 
care homes in relation to the COVID-19 pandemic 

2.1  National LTC context in Cyprus before the pandemic  

The global health emergency caused by the spread of COVID-19, as declared by the World 
Health  Organisation  (WHO)  on  11  March  2020,  forced  the  Republic  of  Cyprus’  MoH17  to 
confront long-standing structural challenges and issues in the LTC system. In the context of 
the  increasing  dependency ratio  due  to  the  ageing  Cypriot  population,  a  lack  of  sound  and 
coordinated national strategies and action plans and the fragmentation of services between 
the  MoH  and  Deputy  Ministry  of  Social  Welfare  (DMSW)18,  extraordinary  and  urgent 
measures were needed to rapidly mitigate the  pandemic’s negative effects on the residents 
of care homes. A piecemeal quality assurance framework coupled with an outdated legal and 
regulatory framework for LTC facilities, prevailing underfunding of LTC services, a shrinking 
workforce,  and  the  absence  of  reliable  and  granular  data  constituted  long-standing 

17 In particular the Unit for Surveillance of Communicable Diseases. 

18 Known as the Social Welfare Services (SWS) until 2021 

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Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

challenges  which  required  a  proactive  and  holistic  response.  Further  challenging  factors  
within the Cypriot LTC system pointed to: 

- 

 A lack of collaboration and coordination between the MoH and the Ministry of Social 
Welfare,  

-  Difficulties in setting standards and weak quality assurance mechanisms,  

- 

Increased  misalignment  between  policies  developed  by  regulators  and  the  way  in 
which these translate into practice by home care providers and  

-  Shortage of professionals due to the unattractiveness of working conditions provided 

in the sector.  

2.2  Policy response and objectives of the Joint Initiative 

To  tackle  the  rising  infections  and  deaths  in  LTC  facilities  associated  with  COVID-19,  a 
National  Scientific  Advisory  Committee19  was  appointed  to  work  in  close  collaboration  with 
the DMSW, as well as with care home administrations. Through a proactive and collaborative 
approach,  these  stakeholders  were  assigned  with  designing  a  well-suited  policy  through 
capacity  mapping,  needs  assessment  and  planning  to  ensure  an  adequate  level  of  health 
protection for both residents and staff of LTC residential settings.   

The  joint  action  between  the  MoH  and the  DMSW  was  envisaged  to  address  the  following 
objectives: 

-  Respect the dignity and rights of LTC residents and prevent and manage the spread 

of infectious diseases in a humane and compassionate way; 

-  Continuously  support  care  home  managers  in  the  implementation  of  protocols  for 

safety measures; 

-  Early  identification  of  positive  or  contact  cases  of  COVID-19  through  weekly  testing 

with mobile units and provision of free self-testing kits to care homes; 

-  Ensure  maximum  health  protection  for  LTC  residents,  including  interactive  online 

training for staff and the provision of free PPE; 

-  Determine  the  percentage  of vaccination  coverage  of  care  home  residents  and  offer 

vaccinations to both staff and care home residents; 

-  Document the number of extremely vulnerable people in a care home and ensure that 
they  are  adequately  protected  by  implementing  all  safety  measures,  such  as 
immunisation testing, hygiene, etc. 

19 The National Scientific Advisory Committee was made up of scientists and academics from various disciplines who acted as 
COVID-19 scientific advisors to the government. 

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Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

Figure 2 Main policy objectives of the Cypriot initiative 

The  resulting  policy  of  monitoring  LTC  facilities  during  and  after  the  COVID-19  pandemic 
included a comprehensive series of actions that drew on documents and guidelines from the 
European  Centre  for  Disease  Prevention  and  Control  (ECDC)20  and  the  WHO21  -  including 
hand  hygiene,  personal  protective  equipment  (PPE)  donning  and  doffing  -  and  which  fully 
aligned  with  the  horizontal  priorities  set  by  the  MoH  for  the  protection  of  vulnerable 
populations and for improving safety and quality standards in LTC facilities. The conceptual 
framework adopted was linked to the WHO's recommendation for a multimodal improvement 
strategy22,  which  identifies  five  key  elements  for  improving  infection  prevention  and  control. 
The WHO’s proposed strategy, in this case, consisted of pillars that were implemented in an 
integrated  manner  with  the  common  goal  of  improving  COVID-19  notification  of  infection 
rates and indirectly reducing COVID-19 deaths in care homes. 

Box 1 Components of the WHO's multimodal improvement strategy adopted 

Components of the WHO’s multimodal improvement strategy adopted 

1.  Continuous monitoring: epidemiological COVID-19 surveillance; 

2.  Alignment of standard operating procedures (SOP) for care homes; 

3.  Promotion of volunteerism and active participation; 

20Prevention and control of COVID-19 in long-term care facilities. Accessed at: https://www.ecdc.europa.eu/en/all-topics-
z/coronavirus/threats-and-outbreaks/covid-19/prevention-and-control/LTCF;  

European Centre for Disease Prevention and Control. Surveillance of COVID-19 in long-term care facilities in the EU/EEA, 19 
May 2020. Stockholm: ECDC; 2020. https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-long-term-care-facilities-
surveillance-guidance.pdf;  

European Centre for Disease Prevention and Control. Surveillance of COVID-19 in long-term care facilities in the EU/EEA, 
November 2021. Stockhom: ECDC; 2021. Accessed at: https://www.ecdc.europa.eu/sites/default/files/documents/covid-19-
surveillance-in-long-term-care-facilities-november-2021.pdf; Healthcare-associated infections in long-term care facilities. 
Accessed at: https://www.ecdc.europa.eu/en/healthcare-associated-infections-long-term-care-facilities      

21 WHO, Infection prevention and control guidance for long-term care facilities in the context of COVID-19, 2021. Accessed at: 
https://www.who.int/publications-detail-redirect/WHO-2019-nCoV-IPC_long_term_care-2021.1 (3.05.2024) 

22WHO Multimodal improvement strategy. Accessed at: https://cdn.who.int/media/docs/default-source/integrated-health-
services-(ihs)/hand-hygiene/tools/ipc-cc-mis.pdf?sfvrsn=425b25d_6&download=true (3.05.2024) 

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4.  Continuous  training,  communication,  and  feedback  to  the  managers  of  the  care 

homes; 

5.  Intensification of audits in the care homes; 

6.  Activation of a task force to identify confirmed cases and cluster events. 

2.3  Activities carried out during the Joint Initiative 

The  initiative  on  the  monitoring  of  LTC  facilities  –  developed  by  the  MoH  and  DMSW  – 
included  a  wide  range  of  activities  targeting  different  stakeholders.  Target  groups  were,  on 
the one hand, residents of all care homes in Cyprus, the majority of whom  included people 
over  65  years  of  age  in need  of  care,  with or  without  physical  and/or  mental  comorbidities. 
On  the  other  hand,  all  staff  in  these  LTC  facilities,  such  as  carers,  nurses,  doctors  and 
administrative and support staff, were also targets of this initiative.  

The following activities relied on strong and close collaboration between the DMSV, MoH and 
LTC providers, marking a new cooperation that had not previously been established, due to 
the  traditionally  separate  strands  of  work  carried  out  in  relation  to  LTC  sector  work  as  a 
whole  (including  community  care,  home  care  and  residential  care).  As  shown  in the  Figure 
below,  the  initiative  sought  to:  (i)  enhance  epidemiological  surveillance  through  constant 
monitoring, (ii) set Standard Operating Procedures to be applied across all care homes, (iii) 
provide  capacity-building  training  initiatives  and  strengthen  communication  and  feedback 
channels,  (iv)  increase  audits  in  care  homes  to  ensure  upholding  of  SoPs  and  (v)  develop 
recommendations on how to improve residents’ wellbeing and the overall quality of LTC care 
services. 

Figure 3 Activities implemented through the policy 

2.3.1  Continuous  monitoring: 

epidemiological  COVID-19 

surveillance 

Continuous  monitoring  of  COVID-19  cases  was  carried  out  through  regular  and  weekly 
testing for all working employees and bi-weekly testing for residents of care homes with rapid 
antigen tests;  23 mobile testing  units  across the  country  were  deployed.  Weekly  schedules 
and  appointments  for  testing  were  provided  to  care  home  managers.  Following  the 
identification of a confirmed COVID-19 case, all staff and residents were retested on days 3, 
7 and 14 with rapid antigen tests. 

2.3.2 Alignment of standard operating procedures for care homes 

A  key  aspect  of  the  monitoring  policy  was  to  standardise  and  align  the  standard  operating 
procedures  (SOPs)  across  care  homes.  The  action  included  revising  the  existing  national 

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Synthesis Report 

protocol  for  emergency  preparedness  against  COVID-19  for  care  homes,  focusing  on  the 
development  of  an  emergency  plan  and  on  the  promotion  of  best  practices  in  infection 
control and prevention based on ECDC and WHO input. As a result, a checklist based on the 
revised protocol was finalised (see Box 2) to monitor, assess and audit the compliance of the 
care homes in a standardised manner.  

The action involved the recruitment of medical students who conducted weekly anonymous 
assessment  visits  on-site,  complying  with  the  checklist  of  SOP.  Additionally,  staff  members 
were  educated  on  best  practices,  with  a  focus  on  proper  application,  use  and  disposal  of 
PPE, use of social bubbles, avoidance of indoor crowding, etc. The students received online 
training  and  were  tested  weekly  with  a  rapid  antigen  test  before  going  to  the  care  homes. 
The weekly timetable and schedule (visits in groups of two led by a senior inspector from the 
MoH)  were  provided  to  the  students’  liaison  officers  by  the  MoH.  The  results  of  the  visits, 
including needs and risk assessments, were also analysed in order to adapt the educational 
seminars for the managers and the staff of the care homes.  

Box 2 Checklist and Standard Operating Procedures 

Checklist and SOPs 

The  checklist  is  divided  into  nine  sections.  The  first  and  second  sections  relate  to  general 
health  and  safety  management  and  applied  health  protocols.  The  third  section  deals 
specifically  with  cleaning  and  disinfection  procedures.  The  following  two  sections  cover 
guidelines for residents and employees of care homes. The proper use of appropriate PPE 
is  also  a  key  point mentioned  in the  checklist.  The  final four  sections  are  about monitoring 
whether  the  correct  procedures  are  being  followed  for  confirmed  or  suspected  COVID-19 
cases.  

In  addition,  the  SOPs  have  been  adapted  to  the  care  homes'  needs  and  are  in  line  with 
ECDC  and  WHO  guidelines  on  health  and  safety  measures,  cleaning  and  disinfection, 
screening of staff and residents, management of suspected and confirmed cases, and PPE. 

2.3.3 Intensification of audits in the care homes 

The  initiative  included  a  weekly  schedule  of  audits  based  on  the  checklist  of  designated 
inspectors from DMSW and MoH to monitor care home infrastructures, practices, processes, 
and results and to submit the data as a weekly report to the MoH. 

2.3.4  Continuous  training,  communication,  and  feedback  to  the 
managers of the care homes 

In  line  with  the  ECDC  and  WHO’s  recommendations,  the  initiative  included  weekly  remote 
seminars (four in total) on infection prevention and control and contingency planning for care 
home managers. These focused on raising managers' awareness of the COVID-19 situation, 
on  better  preparedness  planning/management  taking  into  account  the  specificities  of  each 
care home and on the provision of continuous feedback mechanisms with weekly reports on 
the  epidemiological  situation  in  the  care  homes  in  Cyprus.  The  seminars  were  followed  by 
Q&A  sessions  to  jointly  discuss  the  current  COVID-19  issues  and  improve  communication 
and  engagement.  In  addition,  the  managers  of  the  care  homes  were  in  constant  dialogue 
with the officials of the MoH and DMSW via email or in person during the week. 

The  continuous  training  and  feedback  loops  were  pivotal  to  bringing  about  a  significant 
decrease in COVID-19 cases.  

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2.4  Health safety and well-being  

A fundamental aspect of the Cypriot approach to tackling disease prevention and control was 
to  account  for  residents’  psychosocial  needs  (well-being),  which  were  likely  to  be 
compromised  by  infectious  disease  control  measures  such  as  lockdown  and  social 
distancing or isolation when infected, thus impacting on residents’ quality of life. While health 
safety was generally prioritised to limit the spread of COVID-19 cases within the care homes, 
measures  aimed  at  upholding  residents’  well-being  were  nevertheless  implemented  where 
and  when  possible,  as  this  generated  resilience  against  negative  psychosocial  effects 
caused by isolation and loneliness23. Examples of actions implemented in care homes in this 
sense, included: 

-  Provision of tablets for online communication with loved ones; 

-  Collaboration  with  professional  counsellors  and  psychologists  for  mental  health 

workshops and one-on-one visits; 

-  Encouragement of social activities (e.g. cinema nights, group games) and expression 

of feelings through various mediums (e.g. writing, singing, dancing); 

-  Physiotherapy and occupational therapy; 

-  Direct  involvement  of  directors  of  care  homes  in  the  organisation  of  different  social 

activities and in the communication with occupants’ relatives. 

In essence, the Cypriot approach to disease prevention and control in care homes not only 
aimed to limit the spread of COVID-19 but also fostered resilience and maintained the quality 
of life for residents amidst challenging circumstances. 

3.  Peer country approaches 

As part of the peer review, the representatives of the peer countries Germany, Greece, and 
Bulgaria presented their practices developed during the COVID-19 pandemic to monitor and 
improve  long-term  care.  They  shared  insights  into  the  organisational  and  institutional 
backgrounds  of  their  country's  LTC  systems,  the  challenges  faced  by  their  LCT  sectors 
before and during the pandemic, and the measures developed in response to them.  

3.1  Bulgaria 

3.1.1 Background information 

During  the  COVID-19  pandemic,  infections  in  Bulgaria  were  especially  high  among 
individuals aged 40-79, with higher morbidity and mortality observed among users of social 
services,  particularly  those  with  mental  health  problems  or  dementia  and  those  over  the 

23 i, J.L., Basanovic, J. & MacLeod, C. Social activity promotes resilience against loneliness in depressed individuals: a study 
over 14-days of physical isolation during the COVID-19 pandemic in Australia. Sci Rep 12, 7155 (2022). 
https://doi.org/10.1038/s41598-022-11315-4 

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working  age.  As  of  February  2024,  16,371  individuals  in  Bulgaria,  including  3,067  children 
and 13,304 adults, are placed in social services for residential care. The Social Services Act 
governs the provision, financing, quality, and monitoring of social services, with municipalities 
responsible  for  their  provision;  state  and  municipal  budgets  fund  the  services.  Quality 
standards  for  social  services  are  mandatory  for  all  providers,  regardless  of  the  funding 
source, as outlined in the Regulation on the Quality of Social Services. 

3.1.2 Action plan at district and municipal level for integrated health 
and social services for residential care 

The  action  plan  encompasses  several  key  activities.  Firstly,  it  involves  the  development  of 
individualised COVID-19 action plans for each social service or specialised institution. These 
plans  include  implementing  anti-epidemic  measures,  conducting  staff  training  on  infection 
prevention, establishing mechanisms for hiring extra staff if needed, setting up an immediate 
notification  system  to  alert  the  Regional  Health  Service  in  case  of  infectious  diseases, 
devising  action  protocols  for  confirmed  COVID-19 cases,  and  coordinating  with  local  health 
authorities  and  relatives  of  infected  individuals.  Additionally,  at  the  district  level,  there  is  a 
focus  on  creating  an  action  plan  specifically  tailored  for  COVID-19  outbreaks  in  residential 
care  services  and  specialised  institutions.  This  plan  entails  mechanisms  for  providing 
additional  hospital  beds  and  wards  for  COVID-19  treatment  and  arranging  staffing  for 
medical monitoring and care in alternative locations.  

The  primary  objective  of  the  action  plan  is  to  safeguard  the  lives  and  health  of  individuals 
residing in residential care services and specialised institutions, as well as the staff working 
within  these  facilities.  This  overarching  goal  drives  the  development  and  implementation  of 
tailored  COVID-19  action  plans  at  both  individual  service  provider  and  district  levels, 
ensuring comprehensive measures are in place to prevent, detect, and respond to outbreaks 
effectively.  By  prioritising  the  protection  of  users  and  staff  within  these  settings,  the  action 
plan  seeks  to  minimise  the  impact  of  COVID-19  and  maintain  the  safety  and  well-being  of 
vulnerable populations. 

The  monitoring  and  implementation  approach  of  this  plan  involves  two  key  aspects:  firstly, 
controlling  and monitoring  COVID-19  infections  at  the  service  provider  level,  and  secondly, 
limiting  outbreaks  within  the  district.  As  a  result  of  the  measures  taken  by  Bulgarian  health 
and  social  care  authorities,  all  services  across  the  28  administrative  districts  are  currently 
prepared  to  enact  their  plans  in  the  event  of  a  new  outbreak.  Success  factors  include 
effective coordination between national and local authorities and the application of a pyramid 
approach to prevent COVID-19 and other infectious diseases in residential care. 

3.2. Germany 

3.2.1. Background on the German LTC Sector 

According to figures from 2022, out of a population of 84.6 million people, about 5.2 million 
individuals  in  Germany  were  officially  receiving  LTC.  Home  care  played  a  significant  role, 
with 4.3 million people benefiting from care provided either by family members or by around 
15,400 professional care and nursing services. LTC facilities accommodated around 900,000 
individuals,  in  approximately  16,000  residential  facilities  nationwide.  Among  these  facilities, 
11,400  were  nursing  homes.  Some  of  them  offer  also  daycare  and/or  short  term  care.  In 
total,  there  are  5,900  daycare  institutions.  The  sector  employs  approximately  1.26  million 
individuals  across  all  LTC  facilities.  Prevention  measures  for  the  spread  of  infectious 
diseases in the German LTC system  are regulated through the federal “Infection Protection 
Act”  (Infektionsschutzgesetz),  which  makes  the  German  Federal  MoH  responsible  for 

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overseeing  the  tracking  of  infectious  diseases  in  LTC  settings.  The  MoH  is  responsible  for 
implementing  measures  and  monitoring  the  spread  of  infectious  diseases.  In  addition, 
German legislation for mandatory LTC insurance mandates quality assurance audits of LTC 
facilities.  All  licensed  care  facilities  and  services  must  ensure  the  provision  of  care  while 
respecting  human  dignity.  Licenced  LTC  facilities  are  also  obliged  to  implement  quality 
management  and  to  define  quality  assurance  procedures  based  on  professionally  defined 
standards. Furthermore, providers need to cooperate in yearly quality inspections.  

3.2.2. Action Plan Autumn/Winter 2022/23 (“Herbstkonzept”)  

Coordination  for  the  Action  Plan  Autumn/Winter  2022/23  was  led  by  the  Federal  MoH  in 
collaboration with the self-regulating body of LTC Insurance funds and national care provider 
organisations  known  as  the  "Qualitätsausschuss  Pflege"  (quality  committee  for  care).  The 
focus  was  on  all  residential  care  homes,  aiming  to  raise  awareness  and  enhance 
preparedness  for  the  seasonal  increase  in  COVID-19  infections  during  the  autumn  and 
winter of 2022/23. The main activities included legislative measures, included in the Infection 
Law  Reform  Act  of  September  2022,  which  mandated  care  homes  to  designate  staff 
members  responsible  for  hygiene,  testing,  vaccination,  and  medication.  Coordination  and 
guidelines  were  established  by  the  quality  committee  for  care,  ensuring  consistency  and 
effective implementation across the sector. 

The  main  objectives  of  the  action  plan  were  to  raise  awareness  and  preparedness  in  all 
residential care homes to effectively manage the seasonal increase in  COVID-19 infections 
during  the  autumn  and  winter  months  of  2022/23.  This  initiative  included  promoting 
infection  control,  defining  of 
preventive  measures 
responsibilities and ensuring clear communication channels,. These measures were aimed at 
empowering  LTC  homes  to  proactively  mitigate  the  impact  of  seasonal  rises  in  COVID-19 
infections,  protecting  the  health  and  well-being  of  residents  and  staff.  Vaccination  rates 
among  both  staff  and  residents  were  monitored  from  April  2022  until  April  2023,  while 
promoting vaccinations in parallel. 

like  vaccination,  hygiene  and 

The monitoring and evaluation of the implementation of the action plan, alongside assessing 
organisational adjustments and outcomes, included infection rate trends and implementation 
insights.  Notable  outcomes  included  the  widespread  adoption  of  organisational  changes 
within care homes and an increase in vaccination rates until December 2022, coinciding with 
the  conclusion  of  mandatory  vaccinations  for  LTC  staff.  Key  success  factors  included  the 
involvement  of  self-regulating  bodies  and  LTC  providers,  as  well  as  soliciting  practical 
feedback through ongoing evaluations, including opinion surveys and focus groups from LTC 
facilities and staff. Practical insights gained from these evaluations were pivotal in supporting 
learning  processes  and  organisational  development,  highlighting 
importance  of 
incorporating such approaches for future initiatives. 

the 

3.3  Greece 

3.3.1  Background  on  Greek  government  action  on  healthcare-
associated infections and antibiotic-resistant pathogens 

The  Greek  authorities  have  implemented  a  series  of  legislative  measures  to  combat 
infectious  diseases  over  the  years.  Beginning  in  2014  with  the  introduction  of  the 
"Procrustes" system, they established a surveillance system targeting carbapenem-resistant 
pathogens  and  other  significant  infectious  agents.  Internal  hospital  regulations  were  also 
enforced, including committees for infection prevention and control, education, and strategic 
planning, with participation mandated for hospitals and dialysis centres. In subsequent years, 

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Synthesis Report 

further  steps  were  taken,  such  as  issuing  directions  for  antimicrobial  use  in  hospitals, 
restricting  certain  antibiotics,  and  mandating  prescriptions  for  antibiotics  to  curb  over-the-
counter  sales.  By  2022,  healthcare-associated  infections  were  included  in  the  list  of 
reportable  diseases,  necessitating  weekly  reporting  from  all  public  and  private  healthcare 
facilities.  These  comprehensive  measures  reflect  a  concerted  effort  by Greek  authorities to 
address the challenge of infectious diseases through systematic surveillance, regulation, and 
reporting mechanisms. 

3.3.2 Greek action plan 

The Greek action plan against infectious diseases encompasses various key steps. Firstly, it 
involves  nationwide  surveillance  focusing  on  infections,  antimicrobial  consumption,  and 
compliance  with  care  bundles.  Secondly,  the  plan  emphasises  the  implementation  of 
infection prevention and control practices to mitigate the spread of infections. Thirdly, there is 
a focus on promoting prudent antimicrobial use and monitoring antimicrobial consumption to 
combat antibiotic resistance. Additionally, the plan includes educational initiatives, feedback 
mechanisms,  and  awareness  campaigns for  disseminating care protocols.  Research efforts 
are  also  emphasised,  including  participation  in  European  networks  to  stay  abreast  with 
developments.  Lastly,  collaborations  are  fostered  among  government  ministries,  national 
institutions, and global authorities to ensure a coordinated and effective approach to tackling 
diseases. 
infectious 

Key measures include timely identification of infected patients to facilitate swift treatment and 
prevent  further  transmission,  while  primary  care  practices  prioritised  evidence-based 
prescribing and meticulous antimicrobial consumption recording to ensure judicious antibiotic 
use.  National  microbiological  surveillance  networks  like  the  'Greek  System  for  the 
Surveillance of Antimicrobial Resistance’, which are responsible for monitoring the spread of 
antibiotic  resistant  pathogens  in  the  country,  were  bolstered  to  enhance  diagnostic 
capabilities  and  surveillance  efforts,  aiding  early  pathogen  detection  and resistance  pattern 
monitoring.  Hospitals  implement  tailored  infection  prevention  and  control  rules,  while 
antimicrobial  stewardship  committees  oversee  prescribing  practices  and  drive  continuous 
improvement.  These  efforts  collectively  aim  to  curb  the  spread  of  resistant  pathogens, 
mitigating  the  burden  of  antibiotic  resistance  in  both  healthcare  facilities  and  the  wider 
community. 

4.  Discussion points and key learnings 

During the peer reviews, key points discussed by the participants included the importance of 
legal frameworks in long-term care, collaboration between stakeholders, leadership in setting 
up new multistakeholder initiatives, and care monitoring and data collection. 

4.1  Strong legal frameworks 

A  strong  legal  framework  for  monitoring  and  auditing  both  medical  and  social  well-being 
aspects in LTC facilities was considered a key requisite for quality long-term care. The lack 
of such an up-to-date legal framework was identified by the participants as a weakness in the 
Cypriot  LTC  system  during  COVID-19,  as  there  were  no  established  inter-institutional 
mechanisms to effectively monitor the quality of care in LTC settings. The current framework 
and  legislation  governing  care  homes  have  remained  unchanged  since  1991,  lacking 
essential quality criteria and indicators and not having a legal requirement for regular audits. 

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According  to  representatives  of  the  Cypriot  MoH  and  DMSW,  the  Cypriot  government  is 
moving  to  implement  a  new  legal  framework  for  LTC,  which  is  envisaged  to  update  the 
existing  one  as  well  as  implement  a  new  advisory  body  which  will  be  made  up  of 
representatives  from  MoH,  DMSV,  municipalities,  public  and  private  care  home  providers, 
community-based  care  organisations  and  representatives  of  people  advanced  in  age  and 
people living with disabilities; the body will have the right to audit care facilities. 

During the COVID-19 pandemic, rules and regulations were frequently and swiftly adapted in 
Cyprus  and  the  peer  countries  to  accommodate  emergency  measures  in  response  to  the 
needs identified by health authorities. However, as the pandemic fades into memory, there is 
a need for stronger regulatory frameworks to monitor and improve standards of care, which 
should  include  quality  assurance  criteria,  regular  and  effective  audits  and  guidelines  and 
institutionalised  exchanges  between  responsible  government  authorities  as  well  as  other 
relevant stakeholders. This will help solidify the progress made in the establishment of quality 
assurance criteria and coordination between different stakeholders. 

Mandatory LTC insurance in Germany 

Germany  is  the  only  peer  country  where  LTC  is  provided  through  a  compulsory  LTC 
insurance  system.  Social  insurance  funds  cover  90%  of  the  population,  and  private  LTC 
insurance  companies  cover  the  remaining  10%.  Both  types  of  insurance  carry  identical 
benefits and are designed by law as compulsory insurance. 

However,  Germany's  LTC  insurance  does  not  cover  the  full  costs  of  all  care  needs.  The 
social  LTC  insurance  funds  are  financed  by  contributions,  with  enrolled  persons  and 
employers  each  contributing  half.  These  funds  negotiate  contracts  and  remuneration 
agreements  with  all  providers  of  services  and  residential  facilities.  Any  care  residential 
facility  or  service  that  complies  with  the  authorisation/licensing  requirements  is  legally 
entitled  to  provide  care  services  and  bound  to  comply  with  legal  and  professional  quality 
standards. Public facilities and services, those run by non-profit organisations, and those in 
private ownership all operate under the same LTC insurance regulations. 

4.2  Collaboration between relevant stakeholders 

One of the key practices in the Cypriot initiative was the strong coordination between health 
and social authorities, which proved successful in creating a holistic monitoring framework for 
both  healthcare  and  social  well-being  in  Cypriot  LTC.  In  addition  to  the  inclusion  of  social 
care authorities in the monitoring LTC quality, it is crucial to involve other stakeholder groups 
like professional and family caregivers, LTC providers, and representatives of LTC residents, 
including  people  advanced  in  age  and  people  living  with  disabilities;  this  facilitates  new 
insights  into  best  practices in  LTC  and  the  establishment  of  practices  that  ensure a  human 
rights-based  and  person-centred  approach,  enhancing  the  well-being  of  both  staff  and 
people in need of care. The main practices to improve stakeholder coordination and inclusion 
were  the  establishment of  permanent  advisory  institutions,  strong  support  and  guidance for 
LTC  providers  and  close  coordination  between  national,  regional,  and  local  public 
administrations.  

4.2.1 Permanent advisory institutions 

The  establishment  of  permanent  advisory  institutions  was  discussed  to  include  all 
stakeholders, including LTC providers, staff representatives, and representatives of residents 
of LTC homes, like people living with a disease or disability, people advanced in age, as well 
as  people  who  provide  care  to  family  and  loved  ones  at  home.  The  identified  stakeholders 

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would be  involved  in  deliberating,  sharing  perspectives  and  expertise  and advising relevant 
authorities on setting quality standards and standards of practice while respecting the human 
dignity of LTC residents, the physical and mental well-being of staff and the position of LTC 
facilities.  Examples  of  permanent  advisory  institutions  include  the  Elder  Parliament  in 
Cyprus, which represents persons of advanced age and advises the Cypriot government and 
legislature24 on policies regarding inclusion and well-being, as well as the CNCPH in France, 
which  the  French  Government  consults  on  matters  and  legislation  regarding  the  inclusion 
and well-being of people living with disabilities. 

In the absence of multistakeholder approaches, standards of practice may be established by 
authorities relying only on medical experts who may not be able to consider the perspectives 
of  concerned  stakeholders.  This  could  lead  to the implementation  of  measures that  are  not 
always  fit  for  purpose,  infringe  on  the  rights  and  dignity  of  care  recipients,  or  create 
unmanageable conditions for both staff and LTC care facility management.   

Conseil national consultatif des personnes handicapées in France 

The  Conseil  National  Consultatif  des  Personnes  Handicapées  (CNCPH),  is  a  permanent 
advisory  body  of  160  representatives,  which  include  individuals  living  with  disabilities  and 
their  families,  staff  and  trade  unions,  associations  of  LTC  facilities,  local  authorities,  social 
protection  authorities,  researchers,  parliamentarians,  experts  in  the  field  of  disability 
management and major institutions like the Red Cross. The CNCPH was established by an 
act of law in 1975 and has a legally defined mission to ensure the participation of persons 
with disabilities and the formulation of public policies that affect them. The CNCPH meets 11 
times  a  year  and  has  a  wide  legal  mandate  to  consult  the  government  and  legislature  on 
disability-related matters or to propose measures to the French government to improve the 
situation of people living with disabilities, including those who live in LTC settings.25 

4.2.2 Guidance and support for care providers 

Enhancing  quality  assurance  for  the  well-being of  both  medical  and  LTC  residents requires 
fostering  a  collaborative  relationship  between  authorities  and  providers.  This  approach 
should emphasise constructive engagement rather than relying solely on punitive measures 
to ensure compliance with standards and regulations aimed at improving resident health and 
well-being in LTC settings. Rather, the constructive involvement of LTC providers should be 
encouraged  through  capacity-building  efforts  and  guidance  in  adapting  their  standards  of 
practice  concerning  infectious  disease  prevention  and  the  improvement  of  resident  well-
being.  Authorities  should  recognise  the  multifaceted  challenges  confronting  LTC  facilities, 
which  must  uphold  residents’  health  and  dignity while also addressing  rising  care  demands 
and workforce shortages in qualified personnel. 

Therefore,  authorities  should strive to  encourage  a  trusting  relationship with  LTC  providers, 
in  which  staff  and  care  facility  management  can  freely  communicate  the  challenges  and 
issues they face in a cooperative environment with authorities. In turn, this would encourage 

24Pan Cyprian Volunteerism Coordinative Council. Accessed at: https://volunteerism-cc.org.cy/en/stirixi-draseis/gia-
mko/chartografisi-proothisi-anagkon/voyli-ton-
geronton/#:~:text=It%20consists%20of%2056%20'MPs,Health%20and%20Social%20Welfare%20Committees (24.04.2024) 

25 CNCPH – Conseil national consultatif des personnes handicapées 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

the  buy-in  of  LTC  staff  and  management  to  conduct  more  vigorous  monitoring.  Punitive 
approaches  to  compliance  management  could  lead  LTC  providers  and  staff  to  underreport 
issues  at  their  facilities  out  of  fear  of  being  punished  by  the  authorities,  thereby  negatively 
affecting  not  only  the  quality  of  LTC,  but  monitoring  efforts  and  data  collection  overall. 
Regardless,  a  trusting  and  supportive  relationship  between  care  providers  and  authorities 
should  not  lead  to  lax  enforcement  of  regulations  and  standards  regarding  the  health  and 
well-being of people living in LTC settings. 

4.2.3  Bottom-up  coordination  between  relevant  authorities  and 
stakeholders 

The  inclusion  of  local  authorities  and  other  local  stakeholders,  such  as  health  authorities, 
charities,  churches,  and  community-based  care  organisations,  care  facilities,  and  other 
relevant actors, enables coherent decision-making in LTC policy, as feedback and input from 
the  local  stakeholders  from  the  foundation  in  policy  evaluation  and the  assessment  of  best 
practices  in  as  well  as  issues  currently  affecting  the  quality  of  LTC    on  the  local  level  and 
beyond. In under-served areas, local quality assurance and capacity-building efforts in family 
care  are  especially  vital,  as  formal  care capacities  and capabilities  typically  tend to  be  less 
developed. Here, there is an increased need for authorities to utilise and support other care 
settings  like  family  or  community-based  care  and  to  collect  feedback  from  LTC  facilities  in 
underserved  areas  on  what  capacities  and  capabilities  exist,  how  they  can  be  utilised  to 
improve the quality of care and what can be done to support care providers in the periphery. 

4.3  Leadership in LTC 

Leadership  and  proactivity  are  instrumental  factors  when  it  comes  to  setting  up  new 
initiatives to improve the quality of LTC, especially in the absence of strong legal frameworks 
and  procedures.  This  applies  even  more  when  establishing  new  standards  of  practice  or 
improving  quality  assurance  to  ensure  human  rights-based  and  person-centred  LTC 
approaches.  One  of  the  main  challenges  when  authorities  attempt  to  set  up  a  new 
multistakeholder LTC initiative to improve the quality of care is that competencies are often 
divided  between  health  and  social  care  authorities,  which  can  lead  to  difficulties  in 
coordination  between  stakeholders  and  a  lack  of  comprehensive  oversight  of  capacity  and 
quality  of  LTC  facilities. In  addition to this,  there  may  be  different  competencies spread  out 
over  national,  regional  and  local  administrative  levels  in  addition  to  the  multitude  of  other 
non-governmental  stakeholders.  This  oftentimes  fragmented  LTC  landscape  necessitates 
strong leadership by authorities to approach all stakeholder groups and get them to buy into 
new projects or frameworks designed to quality assure and improve LTC.  

Leadership was especially instrumental in the case of the Cypriot initiative between the MoH 
and DMSW for health monitoring of care homes established during the COVID-19 pandemic, 
as Cyprus lacked a strong legal framework and monitoring mechanisms. Thus, the MoH led 
the  establishment  of  a  working  group,  bringing  together  the  relevant  stakeholder  groups  to 
oversee and improve the monitoring and auditing protocols for LTC facilities. 

At  the  same  time,  effective  leadership  is  also  required  to  institutionalise  new  practices  and 
lessons learned during the COVID-19 pandemic relating to LTC standards established during 
the  pandemic.  There  is  a  danger  of  backsliding  into  pre-pandemic  practices  and  the 
dissolution  of  multistakeholder  working  groups  and  regular  exchanges,  which  proved 
effective  in  dealing  with  COVID-19-related  issues.  Therefore,  effective  leadership  is  also 
required to keep stakeholders engaged in multistakeholder initiatives and transfer temporary 
initiatives into established and permanent practices, ideally with a legal framework. 

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Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

4.4  Retention and development of staff capacity and training 

The  COVID-19  pandemic  has  highlighted  the  shortage  of  qualified  staff  in  healthcare 
professions.  During  the  COVID-19  pandemic,  many  measures  were  adopted,  and  staff  of 
LTC  facilities  were  extensively  trained  to  improve  standards  of  practice  on  hygiene  and 
infectious disease management. However, the loss of qualified health and care workforce in 
LTC  facilities  due  to  potentially  unfavourable  working  conditions  could  result  in  the  loss  of 
these  important  skills,  expertise  and  valuable  lessons  learned  during  the  COVID-19 
pandemic.  In  order  to  retain  nursing  staff  and  make  the  profession  more  attractive,  it  is 
essential  to  tackle  potential  underlying  issues  such  as  inadequate  pay,  long  working  hours 
and high stress levels. It is also possible that sone may choose to relocate to other countries 
where working conditions and pay are perceived as more attractive. 

In  addition  to  improved  working  and  pay  conditions  for  nursing  and  care  staff,  training  and 
further  education  could  be  specifically  promoted  as  well  as  innovative  models  of  work 
organisation  in  long-term  care  developed  with  special  consideration  of  a  competence-
oriented  distribution  of  tasks.  Further  professionalisation  of  nursing  staff,  their  roles  and 
competencies  at  all  qualification  levels  could  also  contribute  to  retention  and  increase  the 
attractiveness of the profession. These measures offer more opportunities for advancement 
within the nursing profession, which would be beneficial for both staff and LTC facilities. 

4.5  Monitoring and data collection 

Close  coordination  and  information  sharing  between  health  and  social  care  authorities  and 
relevant  stakeholders  should  be  present  at  the  national,  regional,  and  local  levels  of  the 
administrative  organisation.  In  fact,  these  are  key  to  ensuring  the  transfer  of  data  and 
monitoring insights on the quality and implementation of measures designed to improve the 
health and well-being of people living in LTC settings.  

It is vital that accurate information is collected at the local level and that robust data collection 
and monitoring  are  conducted  by  local  health authorities,  public,  private, (not-)for-profit  and 
community-based  care  organisations  and  facilities,  as  well  as  other  relevant  local  actors. 
This  information  must  be  accessible  to  policymakers  and  national  authorities  in  a  timely 
manner  to  enable  coherent  decision-making  at  a  national  scale  and  provide  workable 
guidance on improving the standards of LTC and monitoring infectious disease outbreaks. 

Monitoring  and  data  collection  should  also  be  coordinated  holistically  between  both  health 
and social care authorities, looking at quality indicators related to health and well-being. This 
would ensure that data and information are available to policymakers to make decisions on 
regulations  and  standards  of  practice  based  on  datasets  that  include  social  and  well-being 
indicators alongside medical and infectious diseases data.  

5.  Conclusion 

The  COVID-19  pandemic  brought  urgency to tackling  long-standing  structural  issues  in  the 
LTC  as  well  as  in  the  healthcare  sector  more  broadly.  The  far-reaching  damage  the 
pandemic  carried  in  terms  of  death  tolls  and  social  repercussions  needs  to  be  taken  as  a 
wake-up  call  to  action  to  tackle  the  complex  challenges  EU  countries  are  already  facing  in 
light of demographic change and the diminishing capacities of the social and health services 

23 

 
 
 
 
Specific analytical support for the Social Protection Committee peer review meeting: Joint 
Initiative between the Ministry of Health and the Social Welfare Services of Cyprus for health 
monitoring of care homes in relation to the COVID-19 pandemic 

Synthesis Report 

in EU Member States. The emergency brought about by COVID-19 provided an opportunity 
for the development of innovative bottom-up approaches to dealing with the prevention and 
management  of  infectious  disease  spread  and  carried  with  it  many  lessons  learned  and 
promising practices that can be pursued and further refined. Specifically, the development of 
an integrated approach to managing the infectious disease spread in Cyprus set precedence 
for: 

-  Collaboration across ministries and organisations, involving all relevant stakeholders 

to overcome work in silos; 

-  Design  of  tailored  measures  for  the  different  target  groups,  including  care  home 

residents and LTC staff; 

-  Allowing for flexibility in the implementation of measures and adaptability to changing 

situations through iterative processes; 

- 

Identification  of  areas  requiring  structural  improvements,  such  as  modernising  the 
legal framework governing LTC policies and monitoring the quality of LTC services. 

Sharing  the  experiences  of  LTC  management  during  the  pandemic  and  exchanging 
perspectives  on  how  future  policies  can  draw  on  lessons  learned  across  countries  is  a 
necessary  reflective  process  to  increase  EU  emergency  preparedness  and  cohesion  more 
broadly.  The  initiative  by  the  Cypriot  Ministry  of  Health  enabled  the  identification  of  good 
and/or  transferable  practices  for  LTC  from  Bulgaria,  Germany,  Greece  and  the  Republic  of 
Cyprus, including:   

-  Continuous  training  and  capacity-building  initiatives  for  healthcare  staff  in  LTC  and 

improvement of overall working conditions for care professionals; 

-  Guidance and support for care providers, with an emphasis on cooperation and trust 

instead of purely punitive compliance approaches; 

-  Creation  of  effective  communication  channels  and  involvement  of  stakeholders 
across levels (ministries, NGOs, LTC staff etc), across fields (health and social well-
being)  and  across  disciplines  (health,  management,  ethics  etc);  incentivising 
leadership and bottom-up initiatives in adapting protocols and guidelines to changing 
conditions and building on continuous ethical and practical discussions;  

-  Auditing  LTC  facilities  to  ensure  adherence  to  health  and  well-being  protocols, 

including continuing data collection on LTC facilities’ capacity and capabilities. 

The  collaborative  efforts  and  innovative  approaches  developed  during  the  COVID-19 
pandemic  highlight  the  importance  of  proactive  measures,  continuous  learning,  and  cross-
border  cooperation  in  addressing  the  complex  challenges  facing  the  long-term  care  sector, 
paving the way for a more resilient and responsive healthcare system in the European Union 

24 

 
 
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