COVID-19 (coronavirus) advice for care providers

Caring for a person with suspected or confirmed COVID-19 in the care home setting

Contents

Training

An eLearning module is available: e-Learning for Healthcare - Coronavirus (opens in a new window).

The programme has been created by Health Education England e-Learning for Healthcare (HEE e-LfH) in response to the Coronavirus (COVID-19) global pandemic.

The programme includes key materials to help the health and care workforce respond to Coronavirus.

Monitoring

Care homes should follow social distancing guidance where possible: GOV.UK - Guidance on social distancing for everyone in the UK (opens in a new window) and shielding for the extremely vulnerable: GOV.UK - COVID-19: guidance on shielding and protecting people defined on medical grounds as extremely vulnerable (opens in a new window).

Undertake daily monitoring for symptoms amongst residents and care home staff.

Assess each resident twice daily for the development of a fever (≥37.8°C), cough or shortness of breath. Immediately report residents with fever or respiratory symptoms to their GP for assessment.

Symptoms of covid-19 are new continuous cough and/or high temperature.

There is increasing anecdotal evidence locally and nationally that care home residents may present without cough or persistent high temperature when they have COVID-19 infection. 

Atypical presentations include:

  • decrease in mobility
  • increased drowsiness – not wanting to get out of bed
  • diarrhoea
  • poor appetite
  • increased confusion

Contact the residents GP/Neighbourhood Team if you suspect COVID-19.

For staff who have COVID-19 symptoms, they should:

Staff who come into contact with a COVID-19 patient while not wearing PPE can remain at work. This is because in most instances this will be a short-lived exposure.

Staff who fall into the clinically vulnerable group should not provide direct care to symptomatic residents.

For individuals/ homes supporting people with a learning disability, there are additional guidelines. Please see NHS - Clinical guide for front line staff to support the management of patients with a learning disability, autism or both during the coronavirus pandemic – relevant to all clinical specialities (opens in a new window).

Isolation and cohorting

If suspected/confirmed Covid19:

  • promptly isolate resident/s in their own room for 14 days, preferably with an en-suite toilet or dedicated toilet facilities
  • the door should remain shut where safe to do so
  • consider displaying a notice on the door indicating droplet and contact precautions
  • have at least one window open if possible
  • all necessary procedures should be undertaken in the resident’s room
  • only essential staff wearing PPE should enter the resident’s room

Download: Notice of isolation

Where single room isolation is not practical, cohort symptomatic residents together in multi-occupancy rooms.

Do not cohort suspected or confirmed patients next to immunocompromised residents.

Residents with suspected COVID-19 should not be cohorted with residents with confirmed COVID-19.

Where possible, staff should only work with either symptomatic or asymptomatic residents.

Monitor other residents for symptoms and report as suspected outbreak if further cases are identified, see outbreaks.

When possible do not use bank or agency staff or ensure block booking for to minimise risk of cross transmission.

Room door(s) should be kept closed where possible and safe to do so. When not possible, ensure the bed is moved to the furthest safe point in the room to try and achieve a 2 metres distance to the open door as part of a risk assessment.

Isolation measures for contacts

Isolation of contacts: residents who have been in contact with a case should be isolated, as best as possible, for 14 days  after last exposure with the case/s.

Cohorting of contacts within one unit rather than individually: consider this option if isolation in single rooms is not possible due to shortage of single rooms when large numbers of exposed contacts are involved.

Protective cohorting of unexposed residents: residents who have not had any exposure to the symptomatic case can be cohorted separately in another unit within the home away from the cases and exposed contacts

Extremely clinically vulnerable residents: should be in a single room and not share bathrooms with other residents.

Possible hospitalisation

If you think one of your residents may need hospitalisation for urgent and essential treatment, consider the following checklist:

  • assess the appropriateness of hospitalisation
  • consult the Advanced Care Plan/Respect document
  • discuss with resident/family/lasting power of attorney

If significant numbers of residents without advanced plans in place please contact your GP and neighbourhood team to support ongoing conversations. Care homes should be reviewing these documents proactively to ensure decisions are in place.

Postpone routine non-essential medical and other appointments. 

Review and postpone all non-essential appointments that would involve residents visiting the hospital or other health care facilities. 

If medical advice is needed to manage routine care, consider arranging this remotely via a phone call with the GP or named clinician.

Promote good hand hygiene practices

Wash hands with soap and water for a minimum of 20 seconds:

  • before and after contact with the person being cared for
  • before putting on and after removal of PPE
  • after cleaning of equipment / environment
  • before leaving the home
  • extend washing to forearms if feel contaminated with respiratory droplets

Alcohol hand rub can be used if hands are not visibly soiled.

Promote hand washing in the home and ensure clear posters displaying technique are displayed.

Encourage all visitors to wash hands on entering and exiting the home.

For more information please download the following posters:

Download: Hand-washing technique with soap and water poster

Download: Wash your hands poster

Download: Wash your hands more often poster

Bare below the elbow: whilst delivering care the worker must be bare below the elbow. This includes no long sleeves, no hand or wrist jewellery/ wristwatch. Ensure fingernails are clean, short and that artificial nail products are not worn. Ensure all cuts/ abrasions are covered with a waterproof plaster/dressing.

Personal protective equipment (PPE)

PPE is an important component of safe working that includes hand hygiene, cleaning surfaces, decontaminating equipment, not touching your face etc that will all reduce the risks of transmission.

Recommended PPE

Download: Additional considerations, in addition to standard infection prevention and control precautions, where there is sustained transmission of COVID-19, taking into account individual risk assessment for this new and emerging pathogen, NHS and independent sector poster (opens in a new window)

The Coronavirus (COVID-19): personal protective equipment (PPE) plan (GOV.UK website, opens in a new window) outlines

  • guidance: who needs to wear PPE
  • delivery to ensure that those who need it can receive it
  • future supply to ensure we have enough to last through the pandemic

Official guidance states we are currently experiencing sustained transmission across the UK. Therefore the following PPE should be used when within 2 metres of a resident:

  • fluid repellent surgical mask (FRSM)
  • gloves
  • apron
  • if there is a risk of splashing*, then eye protection should be worn

*Risk assessment on the use of eye protection should consider the likelihood of encountering a case(s) and the risk of droplet transmission (risk of droplet transmission to eye mucosa such as with a coughing patient) during the episode of care.

How to use PPE

Please see COVID-19: personal protective equipment use for non-aerosol generating procedures (opens in a new window) for guidance

Download: A visual guide to safe PPE poster

Download: Guide to donning and doffing standard Personal Protective Equipment (PPE) poster

Download: Taking off personal protective equipment (PPE) for non-aerosol generating procedures (AGPs) poster

Ensure hands are washed with soap and water before and after putting on/taking off PPE.

When a FRSM is worn it should: 

  • be well fitted covering both nose and mouth
  • not be allowed to dangle around the neck of the wearer after or between each use
  • not be touched once put on
  • be changed when mask become moist or damaged
  • be removed outside the resident’s room, cohort area or 2 metre away from the symptomatic resident and be worn once and then discarded as healthcare (clinical) waste

New aprons and gloves must be worn for each episode of care and new resident /person with safe disposal and hand hygiene after each resident/person contact in line with standard IPC Guidelines.

Sessional use

Please see the latest PPE guidelines GOV.UK - COVID-19 personal protective equipment (PPE) (opens in a new window). The guidelines introduce sessional use of masks and face protection which can be worn continually over a period of time rather than for a single patient/episode of care. For more information download: Additional considerations, in addition to standard infection prevention and control precautions, where there is sustained transmission of COVID-19, taking into account individual risk assessment for this new and emerging pathogen, NHS and independent sector poster (opens in a new window)

Masks should not be worn continually if damaged, soiled, damp, uncomfortable and difficult to breathe. The manufacturers’ guidance should be followed in regard to the maximum duration of use.

Summary

For all care within 2 metres, staff should wear standard gloves and aprons changing for every patient and task,and clean hands between and a FRSM and if risk* of splashes to the face/eyes wear eye/face protection. The FRSM and eye protection can be worn for a sessional basis (more than one patient). If reusable eye protection is worn this should be decontaminated on removal prior to next sessional use.

Please see GOV.UK - COVID-19: infection prevention and control (IPC) (opens in a new window) for more information.

Reduce number of staff and frequency of times entering room of symptomatic resident. Consider the staff that are required to enter the residents room for care and cleaning and how some tasks might be undertaken in one rather than multiple visits. i.e taking on additional tasks to usual.

All staff, including domestic cleaners, must be trained and understand how to use PPE appropriate to their role to limit the spread of COVID-19.

The use of homemade masks is not advised.

*Risk assessment on the use of eye protection should consider the likelihood of encountering a case(s) and the risk of droplet transmission (risk of droplet transmission to eye mucosa such as with a coughing patient) during the episode of care.

Important

  • remember to take breaks and hydrate yourself regularly
  • do not touch the mask or face once it is put on
  • should you mistakenly touch your mask/face then immediately wash your hands

If a resident is being shielded – a single use mask must be worn for that period of care  and clean eye protection if required. For more information on shielding visit GOV.UK - Guidance on shielding and protecting people defined on medical grounds as extremely vulnerable from COVID-19 (opens in a new window).

Ultimately where staff consider there is a risk to themselves or the individuals, they are caring for, they should wear a fluid repellent surgical mask with or without eye protection, as determined by the individual staff member for the care episode/single session.

Shortages of PPE

Due to some shortages of PPE, the health and safety executive (HSE) has produced guidance detailing considerations and how  to optimise PPE supply: GOV.UK - Considerations for acute personal protective equipment (PPE) shortages (opens in a new window).

However ,it should be noted that PPE reuse is only approved under exceptional circumstances where there are acute shortages and it is safe to do so. Reuse of PPE should not be practiced routinely.

Cleaning and decontamination of reusable equipment

Isolation rooms should be cleaned after the rooms of unaffected residents. Cleaning should preferably be completed by those who are providing care to the resident.

Patient care equipment should be single-use items if possible. Reusable (communal) equipment should where possible be allocated to the individual or cohort of residents/patients.

Clean all reusable equipment systematically from the top or furthest away point.

Follow manufacturers guidance for suitability of cleaning products.

Reusable (communal) equipment must be decontaminated:

  • between each patient and after patient use
  • after blood and body fluid contamination
  • at regular intervals as part of equipment cleaning

Decontamination of eye wear/visors

If reusable eye protection( goggles/visor) is worn this should be cleaned on removal prior to next use.

Clean with neutral detergent and rinse then wipe afterwards with a 70% alcohol wipe and leave to dry. Store to avoid possible contamination.

Detergent and chlorine releasing wipes are available as an easy alternative to making up fresh solutions.

There is no need to use disposable plates or cutlery. Crockery /cutlery can be washed by a dishwasher or by hand using household detergent and hand-hot water after use.

Room/environment cleaning

Preparation

  • collect equipment needed
  • cloths and mop heads should be disposable/single use
  • wash hands before putting on PPE(apron/gloves)

Entering room

  • keep door closed, window open
  • bag disposable items as clinical waste

Cleaning process

  • disposable cloths/mops to clean and disinfect all hard surfaces, equipment, sanitary fittings in the room
  • follow manufacturers dilution and contact times
  • dispose of single use items

Clean using either a combined detergent disinfectant solution at a dilution of 1000 parts per million (ppm) available chlorine (av.cl.)  or a neutral purpose detergent followed by disinfection (1000 ppm av.cl.).

For carpeted floors and items that cannot withstand chlorine-releasing agents, consult the manufacturer’s instructions for a suitable alternative to use following, or combined with, detergent cleaning. Steam cleaning could be considered.

Linen and waste

Treat as infectious. For infected linen use alginate bags inside a secondary bag. Do not take the laundry skip inside the isolation room but as close to it as possible and place laundry directly into secondary bag.

When handling linen - do not:

  • rinse shake or sort linen on removal from beds
  • place used/infectious linen on the floor or any other surface e.g. tabletop
  • re-handle used/infectious linen when bagged
  • overfill laundry receptacles
  • place inappropriate items in the laundry receptacle

Laundry must be labelled, dated and stored whilst waiting collection in a designated safe lockable area in line with home policy.

Staff workwear

Wearing PPE will protect staff clothing. Staff should have a uniform or dedicated clothing for work and wash separately from other items in a load not more that half full. Wash on the hottest wash the items will tolerate. Dry items well. Staff wearing their own clothes as a part of care protocol: change clothes at work then transport home in a disposable plastic bag. This bag should be disposed of into the household waste stream. Clothes should be laundered, separately from other household linen, in a load not more than half the machine capacity, at the maximum temperature the fabric can tolerate, then ironed or tumbled-dried.

It is best practice to change into and out of uniforms/work wear at work and not wear  when travelling to and from work.

Waste

All consumable waste items that have been in contact with the infected individual/s should be double bagged in an orange/yellow waste bag and tied.

Waste should be disposed of as category B waste. Store outside in external waste containers to wait collection.

If orange/yellow waste stream is not available, waste must be double bagged, securely tied and set aside for at least 72 hours before being put outside for collection. Store in external waste containers.

Faeces/urine from infected individuals does not require special treatment and can be discharged down the sewer. Individuals should have a dedicated toilet and preferably en-suite WC.

Visitors to the home

Family and friends should be advised not to visit the home, except next of kin in exceptional situations such as end of life.

Visitors should be limited to one at a time to preserve physical distancing.

Visitors must minimise any contact with other residents.

Cancel all gatherings and plan alternative arrangements for communal activities which incorporate social distancing.

Alternatives to in-person visiting should be explored, including the use of telephones or video, or the use of plastic or glass barriers between residents and visitors.

Guidance to support visiting residents Palliative care and end of life situations:

Visiting Residents in Palliative Care and EOL Situations during the Covid Outbreak (opens in a new window)

Outbreaks

Recognising possible outbreaks

Definition: two or more cases in a home of suspected or confirmed COVID-19 in a 14-day period.

Homes will not be closed to admissions or discharges at this time unless a local decision is made to do so in conjunction with the LA/CCG/PHE.

A risk assessment will be completed by CCG/PHE, to support swabbing of symptomatic residents. The risk assessment also assesses the ability to undertake a swab as this may not be possible for all residents (e.g. advanced dementia).

Residents of care homes will be tested for COVID-19 prior to discharge from hospital to determine their COVID-19 status. The result may not available before discharge. The resident should be isolated for 14 days following discharge.

This will not include residents who attend A&E.

Those that have tested positive during the admission will not be tested again prior to discharge.

Reporting outbreaks

Please ensure an outbreak record is maintained so that information is available when CCG /PHE contact the home for an update.

The outbreak can be declared over once no new cases have occurred in the 14 days since the last resident became symptomatic.

Accepting transfers from hospital

It is the responsibility of the discharging organisation to inform the care home of any COVID-19 related issues for patients being discharged to care homes/supporting living. Residents can be discharged before resolution of symptoms.

The Government has committed to increasing testing in care homes for residents with symptoms. This includes testing prior to discharge from hospital. To determine their COVID-19 status.

Where isolation is possible residents should Isolate on return to the care home for a 14-day period.

If medically fit for discharge a confirmed COVID-19 positive patient can, where isolation possible, complete the 14-day isolation period following onset of symptoms/ positive test, in the care home if not completed in the hospital setting.

If COVID positive and unable to isolate e.g. dementia, consider other discharge options to family members with appropriate support (in the family home). If this is not possible, a step-down bed may be considered or assessment on an individual basis, to support discharge from hospital.

What care is required upon discharge?

The care home should provide care as normal.

The Guidance:admission and care of residents in a Care home should be followed: Coronavirus (COVID-19): admission and care of people in care homes (GOV.UK website, opens in a new window).

Discharging COVID-19 patients: Guidance for stepdown of infection control precautions and discharging COVID-19 patients (GOV.UK website, opens in a new window).

Care after death

If the deceased was known or suspected to have COVD-19, there is no need for a body bag. (Viewing is permitted). Infection control precautions should continue following death although it is recognised that risks of transmission are lower.

Report deaths in the home in line with CQC process.

Further guidance available: GOV.UK - Guidance for care of the deceased with suspected or confirmed coronavirus (COVID-19) (opens in a new window).

The safe management of funerals guidance supports those managing or attending a funeral during COVID-19: Guidance updated to support the safe management of funerals (GOV.UK website, opens in a new window)

Staff welfare – health and wellbeing

The current COVID-19 pandemic will affect us all in different ways: physically, emotionally, socially and psychologically. Staff on the front line of health and social care services will experience varying levels of stress and distress at points.

There are a range of resources to help staff look after health and wellbeing of themselves and others:

Please consider using these resources and discussing any staff-related health and wellbeing concerns with your line manager. 

Staff testing

Access criteria

1. Symptomatic health or care worker and/or symptomatic house-hold member of a self-isolating priority health or care worker

2. Works in Worcestershire

3. Individuals are in the first three days of the onset of  COVID-19 symptoms at the time the swab is taken

With the extension to children the swabbing process is as follows:

  • testing is now available for 12-18 year olds on site (tests will be ‘self administered’ & a parent must accompany the child)
  • testing is now available for 5-12 year olds on site (parents will need to administer the swab to the child, whilst in the car) 
  • under 5’s remain unable to be tested

Book staff swabbing

  • download the form: Staff Covid-19 Test Referral Form (opens in a new window)
  • please note that with regard to family members who are symptomatic, causing the worker to self-isolate, just provide the details of the health care worker in the spreadsheet; when they respond to their text they will be able to add in the details of up to 3 symptomatic household members age 5 and over through the online booking process to which they are then linked
  • please send this form to coronavirusasc@worcestershire.gov.uk by 12:30 pm each day; staff will receive a text to their mobiles regarding the arrangements later that day; any requests received after 12.30 will be managed on the following day
    • the individual being tested will receive a text message inviting them to book an appointment; the text message will contain a link to the appointment booking system and a unique 16 digit code
    • the individual will click on the text message link and be directed to the appointment booking system where they will be asked to enter their unique 16 digit code; they will then be able to book a specific appointment for a coronavirus test at a regional testing site
    • the individual will receive a confirmation of their appointment via text message and email; these will contain a QR code, which will need to be shown to security at the regional testing site

The home testing via the Council / CCG is no longer available – this was a pilot for a week and we’ve been advised that it has now ceased. 

Aerosol generating procedures (AGP)

The following procedures are currently considered to be potentially infectious AGPs for COVID-19:

  • intubation, extubation and related procedures, for example, manual ventilation and open suctioning of the respiratory tract (including the upper respiratory tract)
  • tracheotomy or tracheostomy procedures (insertion or open suctioning or removal)
  • bronchoscopy and upper ENT airway procedures that involve suctioning
  • upper gastro-intestinal endoscopy where there is open suctioning of the upper respiratory tract
  • surgery and post mortem procedures involving high-speed devices
  • some dental procedures (for example, high-speed drilling)
  • non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation (BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
  • High Frequency Oscillatory Ventilation (HFOV)
  • induction of sputum
  • high flow nasal oxygen (HFNO)

Chest compressions and defibrillation are not considered AGP.

Fit testing

FFP3 respirators filter at least 99% of airborne particles. The HSE states that all staff who are required to wear an FFP3 respirator must be fit tested for the relevant model to ensure an adequate seal or fit (according to the manufacturers’ guidance). Fit checking is necessary when a respirator is donned to ensure an adequate seal has been achieved.

It is important to ensure facial hair does not the sealing surface as will impact the masks effectiveness: see facial hair and FFP3 poster (assets.publishing.service.gov.uk website, opens in a new window).

For patients with possible or confirmed COVID-19, any of these potentially infectious AGPs should only be carried out when essential. Where possible, these procedures should be carried out in a single room with the doors shut. Only those healthcare staff who are needed to undertake the procedure should be present.

Recommended PPE during AGPs on possible and confirmed cases, regardless of the clinical setting:

  • a long-sleeved disposable fluid repellent gown (covering the arms and body) or disposable fluid repellent coveralls
  • a filtering face piece class 3 (FFP3) respirator
  • a full-face shield or visor and
  • gloves

Respirators can be single use or single session use (disposable) and fluid resistant.

Valved, non-shrouded FFP3 respirators are not considered to be fluid resistant and therefore should be worn with a full face shield if blood or body fluid splashing is anticipated.

FFP3 respirators should:

  • be well fitted, covering both nose and mouth
  • not be allowed to dangle around the neck of the wearer after or between each use
  • not be touched once put on
  • be removed outside the patient room or cohort area or COVID-19 ward

Guidance on the use of personal protective equipment (PPE) for aerosol generating procedures (AGPs) (GOV.UK website, opens in a new window).

Please note

All the posters and other guidance documents are available at the COVID-19 (coronavirus) advice for care providers documents (opens in a new window) page.

For general information and updates please visit the Coronavirus page.