Infection prevention and control in adult social care: COVID-19 supplement

Introduction

As we learn to live safely with coronavirus (COVID-19), this guidance should be used to help reduce the spread of COVID-19 in adult social care settings.

This guidance applies to adult social care settings and services in England and should be read in conjunction with the infection prevention and control (IPC): resource for adult social care guidance, which should be used as a basis for any infection prevention and control response. The devolved administrations will each set out their own guidance.

This supplement provides additional information regarding safe working when caring for people with COVID-19 in the provision of adult social care services. This guidance will be kept under review.

The supplement includes guidance on:

• staff IPC considerations:
  • vaccination
  • personal protective equipment (PPE)
  • staff movement
  • testing
• IPC considerations for people receiving care:
  • vaccination
  • testing
• environmental considerations:
  • ventilation
  • waste management
• considerations specific to care homes:
  • admissions
  • testing
  • visiting
  • outbreak management

This supplement should also be read in conjunction with the adult social care testing guidance, which details the testing regimes for all staff, as well as any resident and care home outbreak testing where applicable.

Adult social care staff IPC considerations

Vaccination

Vaccination remains a primary protection measure against COVID-19, reducing the risk of serious illness, hospitalisation and death. The Secretary of State for Health and Social Care, along with the Chief Medical Officer, the Chief Nurse for Adult Social Care and others, have been clear that all people working in health and social care settings, including volunteers and unpaid carers, have a responsibility to be vaccinated against COVID-19. This is to ensure that safe care is provided to people who receive care and support.

To minimise risk to people who receive care and support, health and social care providers should encourage and support all their staff to get a COVID-19 vaccine and a booster dose as and when they are eligible, as well as a vaccine for seasonal influenza. Providers can do this by putting in place arrangements to facilitate staff access to vaccinations, and regularly reviewing the immunisation status of their workforce in line with immunisation against infectious disease (‘the Green Book’).

Everyone eligible can either book their first dose, second dose and booster dose of a COVID-19 vaccination online via the national booking service, or can attend a walk-in centre.

To ensure the safety of people who receive care, providers should undertake risk assessments wherever possible. These should take into account the COVID-19 vaccination status of both staff members and the people they care for. Relevant clinical advice should be considered, including whether any individuals are at higher risk of severe COVID-19 infection. Further information about assessing the risk of individuals can be found below in the risk assessment section of ‘IPC considerations for people receiving care’. As a result of these risk assessments, providers may consider taking additional steps such as prioritising the deployment of vaccinated staff to care for those who are at higher risk of severe COVID-19 infection, where proportionate.

Testing

For more information on symptomatic, rapid response and outbreak testing processes in adult social care services see Coronavirus (COVID-19) testing for adult social care services.

Personal protective equipment

Appropriate PPE should be worn by care workers and visitors to residential care settings, subject to a risk assessment of likely hazards such as the risk of exposure to blood and body fluids. The advice below provides guidance on the type of PPE that is recommended, to help protect care workers and care recipients and prevent the transmission of infectious diseases, with particular advice regarding care of people suspected or confirmed to be COVID-19 positive.

For PPE to be effective, it is important to use it properly and follow instructions for putting it on (donning) and taking it off (doffing).

All used PPE should be disposed of appropriately according to the waste management section below.

Gloves, aprons and eye protection

In addition to recommendations for standard precautions (for example, when there is a risk of contact with blood or body fluids), gloves and aprons should be worn when the care worker or visitor is providing close care for a person who has suspected or confirmed COVID-19. These should be removed and disposed of upon leaving the room.

If the person being cared for has suspected or confirmed COVID-19, it is recommended that eye protection is worn when providing close care for them, or when cleaning their room. Eye protection should be worn if there is a risk that splashes, droplets or secretions from the person’s mouth, nose, lungs or body fluids may reach the care worker or visitor’s eyes, and when undertaking aerosol-generating procedures (AGPs) (see section below on AGPs). If eye protection is used, this should be removed after leaving the room. If providing care in the person’s own home, eye protection should be removed when leaving their house. Reusable eye protection should be cleaned and disinfected as per the manufacturer’s instructions between use.

Face masks

Face masks should be worn by all care workers and encouraged for visitors in care settings and when providing care in people’s own homes, irrespective of whether the person being cared for is known or suspected to have COVID-19 or not. This is sometimes referred to as ‘universal masking’ or ‘source control’ and is a means of preventing any spread of infection from the mask wearer.

There are a variety of different face masks which are useful for both protecting the wearer (PPE) and protecting others (source control). However, the type of mask recommended depends on the type of activity being undertaken and whether the person is known or suspected to have COVID-19 or not.

All face masks should:

• be well fitted to cover nose, mouth and chin
• be worn according to the manufacturer’s recommendations (check which side should be close to the wearer)
• not be allowed to dangle around the neck at any time
• not be touched once put on
• be worn according to the risk-assessed activity
• be removed and disposed of appropriately, with the wearer cleaning their hands before removal and after disposal

Face masks should be changed:

• if they become moist
• if they become damaged
• if they become uncomfortable to wear
• if they become contaminated or soiled
• at break times
• after 4 hours of continuous wear
• between different people’s homes

There may be circumstances where the use of face masks inhibits communication or is challenging for the client. This should be taken into account as part of a risk assessment, and consideration should be given to how best to put PPE guidance into practice to minimise any negative impact on people receiving care, while maintaining infection prevention and control. This may, for example, be appropriate when supporting individuals with learning disabilities or cognitive conditions such as dementia, if they find the use of PPE distressing, or when supporting individuals for whom lip reading or facial recognition is important. Where this is the case, other appropriate mitigations should be considered such as limiting close contact and increasing ventilation. The needs of the person receiving care should be recognised and they should be as involved as they wish to be, and are able to be, in determining their needs in these circumstances.

It may be appropriate in certain circumstances to consider transparent face masks, some of which could be considered for use as an alternative to type IIR surgical masks (see below for more detail).

Transparent face mask technical specification offers further guidance.

Type I and type II face masks

Type I and type II masks are not considered PPE and are worn to provide source control – that is, to protect others from the wearer’s respiratory droplets should they have asymptomatic COVID-19 infection. A type I or type II mask should be worn in care settings when undertaking any social, care or domestic activity that does not involve close care with, or cleaning the room of, an individual with suspected or confirmed COVID-19 or contact with blood or body fluids. This is because type I and II masks are not fluid repellent. A type IIR mask (see below) may also be worn for these purposes.

Face masks are not routinely required when supporting someone outdoors as exhaled air is quickly dispersed. Care staff should consider wearing face masks if supporting people in indoor public spaces outside of a care setting.

Type IIR face masks

Type IIR fluid-repellent surgical masks protect the wearer by providing a fluid repellent barrier between the wearer and the environment. This protects the wearer against blood or body fluid splashes and against the respiratory droplets of others reaching their mouth and nose. These masks also protect others from the wearer’s respiratory droplets should they have asymptomatic COVID-19 infection. Workers should wear a type IIR fluid-repellent surgical face mask when providing close care for people who are symptomatic, suspected or confirmed as having COVID-19 or when cleaning their rooms. A type IIR mask should also be worn when undertaking any task where there is a risk of splashing with blood or body fluids.

Use of face masks for care ‘sessions’

In communal care settings, face masks of all types can be used for source control and can be worn sessionally, that is for a maximum of 4 hours, unless the worker is providing personal care or cleaning the room of someone with suspected or confirmed COVID-19 or is carrying out an AGP (see section below). After 4 hours, or after leaving the room (or cohorted area) of someone with suspected or confirmed COVID-19 (whichever is sooner) masks should be disposed of and replaced with a new mask. Masks should also be replaced if they become contaminated, dirty, damp or after being removed for breaks or to allow the care worker to eat or drink.

Staff who are providing personal care to someone with known or suspected COVID-19 in a residential care setting should dispose of their face mask after leaving the individual’s room, and put a new mask on. The only exception to this is if a care worker is caring for a cohort of people who have been grouped together for their care because they are in a group suspected to have COVID-19 or are in a group confirmed to have COVID-19. If all people the care worker is caring for have COVID-19, the worker may continue to wear a type IIR mask sessionally after providing personal care to someone with COVID-19. If they are then called to provide care for someone who does not have COVID-19, this mask should be removed and disposed of once outside of the room and a new mask put on.

Homecare workers should remove their masks when leaving the home of the person they are caring for and wear a new mask when entering different people’s homes.

Aerosol-generating procedures (AGP)

An AGP is a medical procedure that can cause the release of virus particles from the respiratory tract and can increase the risk of airborne transmission to those in the immediate area. AGPs in the community setting include tracheostomy procedures (insertion or removal) and open suctioning beyond the oro-pharynx.

Filtering face piece class 3 (FFP3) respirators are required when you are undertaking AGPs on a person with suspected or confirmed COVID-19 infection, or another infection spread by the airborne or droplet route. FFP3 respirators should be removed outside of the room where the AGP was carried out and disposed of. They should then be replaced with a type I, II or IIR mask depending on what is most appropriate for the next task. If undertaking an AGP in someone’s own home, FFP3 respirators and face masks should be removed and disposed of when leaving the house.

The use of FFP3s is governed by health and safety regulations and they should be fit tested to the user to ensure the required protection is provided. The Health and Safety Executive (HSE) provides information and tools to help select and manage the use of respiratory protective equipment (RPE).

Workers should wear a type IIR mask when carrying out an AGP on someone who is not suspected or confirmed to have COVID-19 or another infection spread via airborne or droplet routes.

Workers should wear gloves, aprons and eye protection when carrying out AGPs. Where there is an extensive risk of splashing, workers should wear gowns instead of aprons.

Following an evidence review commissioned by NHS England and Improvement, the list of procedures which are currently classed as AGPs in relation to COVID-19 are:

• awake bronchoscopy (including awake tracheal intubation)
• awake ear, nose, and throat (ENT) airway procedures that involve respiratory suctioning
• awake upper gastro-intestinal endoscopy
• dental procedures (using high-speed or high-frequency devices, for example ultrasonic scalers or high speed drills)
• induction of sputum
• respiratory tract suctioning
• tracheostomy procedures (insertion or removal)

‘Awake’ includes conscious sedation (excluding people who are anaesthetised with secured airway).

The available evidence relating to respiratory tract suctioning is associated with ventilation. In line with a precautionary approach, open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list. It is the consensus view of the UK IPC cell that open suctioning beyond the oro-pharynx is currently considered an AGP – that is, oral or pharyngeal suctioning is not an AGP.

Certain other procedures or equipment may generate an aerosol from material other than patient secretions but are not considered to represent a significant infectious risk for COVID-19. In care settings, procedures commonly undertaken which are not classified as AGPs include:

• non-invasive ventilation (NIV)
• bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
• high flow nasal oxygen (HFNO)
• oral or pharyngeal suctioning (suctioning to clear mucus or saliva from the mouth)
• administration of humidified oxygen
• administration of Entonox or medication via nebulisation

PPE recommendations summary

The tables below detail some common scenarios in care and the appropriate PPE to be worn.

Table 1: PPE requirements when caring for a person not known or suspected to have COVID-19

Note: sessional use of masks applies to communal care settings only. Homecare workers should remove their masks when leaving the home of the person they are caring for and wear a new mask when entering different people’s homes.

Table 2: PPE requirements when caring for a person with suspected or confirmed COVID-19

Staff movement

Care services are not normally required to limit staff movement between sites or services. However, they may be asked to limit staff movement by the local Director of Public Health or health protection team (HPT) if, for example, there is high prevalence of COVID-19 locally or in an outbreak. For further information see below on outbreak handling.

If a staff member develops COVID-19 symptoms

Anyone who has symptoms of a respiratory infection (see below) and has a high temperature, or anyone who has symptoms of a respiratory infection and does not feel well enough to work is advised to stay at home and avoid contact with other people.

For social care staff eligible for free testing, lateral flow tests are available for staff who are concerned they may be experiencing symptoms of COVID-19. Social care staff who have symptoms of a respiratory infection and who have a high temperature, or social care staff who have symptoms of a respiratory infection and do not feel well enough to attend work should take a lateral flow test as soon as they feel unwell (day 0). They should not go to work, and if at work, should leave as soon as possible. Staff with respiratory symptoms who feel well enough to work and do not have a temperature, do not need to take a symptomatic test and can continue working.

If the result of this lateral flow test is positive, staff should follow the advice in the section ‘If a staff member receives a positive lateral flow or PCR test result’.

If the lateral flow test result is negative, they should take another lateral flow test 48 hours later, staying away from work during this time.

If the second lateral flow test is also negative, they can return to work if well enough to do so.

If either test is positive, they should follow the guidance in the section ‘If a staff member receives a positive lateral flow or PCR test result’.

Free lateral flow tests have been provided for symptomatic testing and staff should ensure they have some at home for this purpose. For more information on accessing COVID-19 tests, see the adult social care testing guidance.

For staff who test negative but have a temperature or feel too unwell to work on the first day but then feel better the following day, in exceptional circumstances and subject to the below risk assessment, these staff may be able to work. If a risk assessment indicates a serious risk to social care service delivery, symptomatic staff who test negative on day 0, who do not have a temperature and feel well enough to do so may be asked to return to work. The risk assessment should consider avoiding contact with people at higher risk of serious illness where possible. Further information about assessing the risk of individuals can be found below in the risk assessment section of ‘IPC considerations for people receiving care’. On returning to work, the staff member must continue to comply rigorously with all relevant infection control precautions and PPE must be worn properly throughout the day. The staff member should take another lateral flow test 48 hours after their first test and if this second test is negative, they can remain working.

Symptoms of COVID-19, flu and common respiratory infections include:

• continuous cough
• high temperature, fever or chills
• loss of, or change in, your normal sense of taste or smell
• shortness of breath
• unexplained tiredness, lack of energy
• muscle aches or pains that are not due to exercise
• not wanting to eat or not feeling hungry
• headache that is unusual or longer lasting than usual
• sore throat, stuffy or runny nose
• diarrhoea, feeling sick or being sick

Any of these symptoms may also have another cause. Particular judgement should be applied to those who may experience symptoms on this list routinely as part of a pre-existing health condition in order to distinguish these symptoms from symptoms of COVID-19.

If staff members are concerned about their symptoms, they should seek medical advice.

If a staff member receives a positive lateral flow or PCR test result

To avoid passing on the virus, anyone who receives a positive lateral flow or PCR test result should follow the advice regarding staying at home and avoiding contact with other people from the day they test positive or develop symptoms (day 0). There is no need to take a PCR test after a positive lateral flow test result.

In addition, social care staff with COVID-19 should not attend work until they have had 2 consecutive negative lateral flow test results (taken at least 24 hours apart), they feel well and they do not have a high temperature. The first lateral flow test should only be taken from 5 days after day 0 (the day their symptoms started, or the day their test was taken if they did not have symptoms). If both lateral flow tests results are negative, they may return to work immediately after the second negative lateral flow test result on day 6, if their symptoms have resolved, or their only symptoms are cough or anosmia which can last for several weeks.

If the staff member cares for people who are at higher risk of becoming seriously unwell with COVID-19 (seek clinical advice as necessary), careful assessment should be undertaken, and consideration given to redeployment until 10 days after their symptoms started (or the day their test was taken if they did not have symptoms). The staff member should continue to comply with all relevant infection control precautions and PPE should be worn properly throughout the day. Further information about assessing the risk of individuals can be found below in the risk assessment section of ‘IPC considerations for people receiving care’.

A positive lateral flow test in the absence of a high temperature after 10 days is unlikely. If the staff member’s lateral flow test result remains positive on the 10th day, they should continue to take daily lateral flow tests. They can return to work after a single negative lateral flow test result.

The likelihood of a positive lateral flow test after 14 days is considerably lower. If the staff member’s lateral flow test result is still positive on the 14th day, they can stop testing and return to work on day 15. If the staff member works with people who are at higher risk of becoming seriously unwell with COVID-19 (seek clinical advice as necessary), a risk assessment should be undertaken, and consideration given to redeployment.

Managers can undertake a risk assessment of staff who test positive between 10 and 14 days and who do not have a high temperature or feel unwell, with a view to them returning to work depending on the work environment.

If a staff member receives a negative or inconclusive test result

Staff who had symptoms of COVID-19 and who received negative results (2 lateral flow tests 48 hours apart as per the symptomatic section above) can return to work providing they are medically fit to do so, subject to discussion with their line manager or employer and a local risk assessment.

Staff who receive an inconclusive test result should take another lateral flow test, and symptomatic staff who do not have immediate access to another lateral flow test should not attend work while waiting to receive another lateral flow test to take. If the test was being taken by an asymptomatic member of staff as part of outbreak testing, they can continue working but should still take the repeat test. If the repeat test result is positive, they should follow the advice on receiving a positive test (see above). If their test result is negative, they can return to work.

Staff who are contacts of confirmed COVID-19 cases

Staff who are contacts of confirmed COVID-19 cases can continue working. They should comply with all relevant infection control precautions and PPE should be worn properly throughout the day. They no longer need to undertake any additional testing.

If the staff member develops symptoms, they should follow the guidance for ‘If a staff member receives a positive lateral flow or PCR test result’.

If the staff member works with people who are at higher risk of becoming seriously unwell with COVID-19 (seek clinical advice as necessary), a risk assessment should be undertaken, and consideration given to redeployment during the 10 days following their last contact with the case. Further information about assessing the risk of individuals can be found below in the risk assessment section of ‘IPC considerations for people receiving care’.

Consideration should be given to how to ensure staff can deliver safe care during the 10 days after being identified as a close contact of someone who has tested positive for COVID-19. This includes applying the measures known to reduce risk such as distancing, maximising ventilation, PPE and cohorting. This should be built into provider’s general risk assessments for responding to infectious diseases and ensuring safe staffing levels are maintained.

Care workers living with individuals they provide care and/or support to

Care workers who provide care and/or support to the person they live with may need to follow different guidance detailed in this section given the close proximity of the care and the relationship between carer and the individual receiving care.

In addition, care workers and their employer, where relevant, will need to undertake a risk assessment to determine which PPE to use and this should involve the supported person’s views and preferences. This risk assessment may include wearing of type I or II masks for source control (that is, the mask is worn to protect others from the wearer). This might be at the start of a placement or for short placements.

If a care worker is living with the supported individual and they are considered a part of the household, they do not normally need to wear PPE when doing domestic duties. However, they should wear PPE if the person they support, or a member of their household, develops respiratory symptoms such as coughing or sneezing, or tests positive for COVID-19 – in which case follow the guidance in Table 2 above. It remains important that they continue to use the PPE needed for the care they provide. For example, gloves and an apron should be worn if they are handling soiled linen, or if they may come into contact with body fluids such as urine, faeces or blood. Please refer to the PPE recommendations summary section in the infection prevention and control: resource for adult social care guidance for further information.

All care workers should follow the same symptomatic testing guidance, regardless of whether they are living with the person they provide care and/or support to.

If a care worker becomes symptomatic or tests positive they should stay away from the individual they provide care for. The care worker should leave the individual’s home where possible and follow the guidance for staff who are symptomatic or have tested positive provided above.

If the individual who is receiving care and/or support is living in the care worker’s home (for example, this may happen in Shared Lives arrangements), and the care worker has tested positive, the supported person should leave the home if possible and they should follow the guidance for people receiving care who are contacts of those with COVID-19. If they are unable to leave the home, they should continue to follow the guidance for contacts. Providers and care workers, in discussion with people in their care where possible, should ensure there are contingency plans in place should this need to happen and this should be a part of the risk assessment at the outset.

IPC considerations for people receiving care

Vaccination

Vaccines are the best way to protect people from COVID-19 and people receiving care are encouraged to get their COVID-19 vaccinations, including boosters, as soon as they are eligible. Furthermore, wherever possible they are encouraged to get their COVID-19 vaccines ahead of entering adult social care settings. See the COVID-19 vaccination: guide for adults for advice on who is eligible for, and where to book vaccines.

Risk assessment

When assessing if a person is at higher risk of severe COVID-19 infection, use Who is at high risk from coronavirus (COVID-19) as a guide, but allow for individual risk assessment and judgement. Other factors may also be relevant and should be taken into account – seek clinical advice as required.

If a person receiving care is symptomatic or tests positive

People who are older or frail, or have cognitive conditions, such as dementia, may present with atypical symptoms or feel different from usual which should also be considered as part of the assessment about whether someone may have COVID-19. Changes in wellbeing, behaviour and clinical signs with or without a high temperature should all be considered and clinical advice sought if necessary, for example from the GP if the person is unwell.

If someone receiving care who does not live in a care home has symptoms of a respiratory infection and has a temperature, or has symptoms of a respiratory infection and is too unwell to carry out their usual activities, or tests positive for COVID-19, they should be encouraged to follow the advice for the general population which is to stay at home and avoid contact with others. As noted above, atypical symptoms should also be considered.

In addition, in extra care and supported living, symptomatic residents have access to free lateral flow testing to check if they have COVID-19. Residents who have symptoms of a respiratory infection and have a high temperature, or residents who have symptoms of a respiratory infection and are too unwell to carry out their usual activities should take a lateral flow test as soon as they feel unwell (day 0). As noted above, atypical symptoms or generally feeling unwell should also be considered for people who are older or frail, or have cognitive conditions, such as dementia, and clinical advice sought if necessary.

Residents should immediately take a lateral flow test as soon as they develop symptoms and if this first test is negative, they should take another lateral flow test 48 hours after the first test.

If this test is also negative they can return to their usual activities if well enough to do so.

If either test is positive, they should follow the advice for the general population to stay at home and avoid contact with others.

If the individual lives in a residential setting that is similar to a care home, such as in an extra care and supported living service, providers may wish to follow all or some of the guidance for symptomatic care home residents as set out in the section below on care home residents who are symptomatic or test positive for COVID-19.

Environmental considerations

Ventilation

In addition to standard precautions, particular attention should be given to how ventilation can be improved. Ventilation is an important control to manage the threat of COVID-19. Letting fresh air into indoor spaces can help remove air that contains virus particles and prevent the spread of COVID-19.

Where possible, rooms should be ventilated after any visit from someone outside the setting, or if anyone in the care setting has suspected or confirmed COVID-19. This is because ventilation is particularly important in spaces which are shared with other people for longer periods of time.

The comfort and wishes of the person receiving care should be considered in all circumstances, for example balancing with the need to keep people warm. Rooms may be able to be repurposed to maximise the use of well-ventilated spaces.

Further information regarding ventilation can be found in Infection prevention and control: resource for adult social care and Ventilation of indoor spaces.

Waste management

In addition to standard precautions the following should be observed:

• in a care home, waste generated when supporting a person with confirmed COVID-19 should enter the hazardous waste stream (usually an orange bag)
• waste visibly contaminated with respiratory secretions (sputum, mucus) from a person suspected or confirmed to have COVID-19 should be disposed of into foot-operated lidded bins which should be lined with a disposable waste bag
• if there is not access to a hazardous waste stream, such as waste generated in people’s own homes, this should be sealed in a bin liner before disposal into the usual waste stream

Considerations specific to care homes

Resident IPC considerations

Admission of care home residents from a care facility or the community

Residents should take both of the following:

• a PCR test within the 72 hours before they’re admitted (or a lateral flow test if they have tested positive for COVID-19 in the past 90 days)
• a lateral flow test on the day of admission (day 0)

These tests should be provided by the care home. If an individual tests positive on either of these tests and continues to be admitted to the care home, they should be isolated on arrival and follow the guidance on care home residents who are symptomatic or test positive for COVID-19.

Urgent care home admissions from the community

For urgent admissions to a care home from the community, the care home manager should find out whether the resident being admitted has had a lateral flow or PCR test and, if so, when and what the result was.

If the individual has taken a lateral flow or PCR test within 72 hours of the urgent admission into the care home, the care home manager should share the result with the relevant and responsible person. This may be a delegated responsibility.

If a PCR or lateral flow test has not been taken or was taken more than 72 hours before urgent admission, the individual should be tested again with a lateral flow test by the care home. If the test result is positive, the individual should isolate in the care home and follow the guidance below on care home residents who are symptomatic or test positive for COVID-19.

Discharge from hospital into a care home

The NHS will do a PCR test within 48 hours prior to an individual’s discharge into a care home, or a lateral flow test if the individual has tested positive for COVID-19 in the last 90 days.

The test result should be shared with the individual themselves, their key relatives or advocate and the relevant care provider before the discharge takes place.

If an individual tests positive prior to discharge, they can be admitted to the care home, if the home is satisfied they can be cared for safely.

If an individual returning or being admitted to a care home has tested positive for COVID-19, they should be isolated for a total period of 10 days from the day symptoms started or the day of the positive test if asymptomatic (counting the day of symptom onset or the original positive test as day 0). This isolation period should include days in the hospital, so when entering a care home, they only need to isolate for the remainder of the 10 days since symptoms or positive test.

However, if an individual who is isolating can participate in testing, they may undertake daily lateral flow testing from day 5 (counting the day of symptom onset or the original positive test as day 0). They can end isolation after receiving 2 consecutive negative tests 24 hours apart.

Any individual who is unable to test should be isolated for the full 10 days following symptom onset or a positive test if asymptomatic. Isolation should only be stopped when there is an absence of fever (less than 37.8°C) for 48 hours without the use of medication.

If an individual tests negative for COVID-19 and has no symptoms of COVID-19 and is being discharged to a care home from a location in the hospital where there was an active outbreak, they should be isolated for 10 days from the date of admission to the care home, regardless of whether their overnight hospital stay was planned (elective) or unplanned. This is to prevent possible introduction of infection into the care home. Information about hospital outbreak status should be provided as part of the discharge process. Individuals who are isolating for this reason and who are able to participate in daily testing may have lateral flow testing from day 5 (counting the day of admission to the care home as day 0). They can end isolation after 2 consecutive negative tests 24 hours apart, or after 10 days’ isolation if they remain asymptomatic.

During isolation, residents should be enabled to receive one visitor at a time (this does not need to be the same visitor throughout the isolation period) and have access to outside space to assist rehabilitation if possible.

Care home residents who are contacts of confirmed cases

Care home residents who are close contacts of a COVID-19 case are no longer advised to isolate nor undertake additional testing. Instead, it is advised that they:

• minimise contact with the person who has COVID-19
• avoid contact with anyone who is at higher risk of severe COVID-19 infection (see the risk assessment section of ‘IPC considerations for people receiving care’)
• follow the advice regarding testing and isolation if they develop symptoms of COVID-19

Care home residents who are symptomatic or test positive for COVID-19

Residents who have symptoms of a respiratory infection and have a high temperature, or residents who have symptoms of a respiratory infection and are too unwell to carry out their usual activities, should take a lateral flow test as soon as they feel unwell (day 0). People who are older or frail, or have cognitive conditions, such as dementia, may present with atypical symptoms or feel different from usual which should also be considered as part of assessing whether they should be tested for COVID-19. Changes in wellbeing, behaviour and clinical signs with or without a high temperature should all be considered when undertaking an assessment about testing and clinical advice sought if necessary, for example from the GP if the person is unwell.

If the lateral flow test result is negative, they should take another lateral flow test 48 hours later, avoiding others during this time.

If the second test is also negative they can return to their usual activities if well enough to do so.

If either test is positive, the guidance below should be followed regarding isolation and support for residents who test positive.

All residents who test positive for COVID-19 with either lateral flow or PCR tests, regardless of whether they are symptomatic or asymptomatic, should isolate in the care home for 10 days from when the symptoms started, or from the date of the test if they did not have symptoms. The care home manager should inform the resident’s GP and should:

• support the resident to self-isolate for 10 days within their own room – it may be possible to reduce the period of isolation (see below for further information)
• closely monitor the resident’s symptoms
• consider if the resident is eligible for COVID-19 treatments including antivirals or monoclonal antibodies

Isolation does not preclude:

• receiving one visitor at a time (this does not include visiting professionals)
• going into outdoor spaces within the care home grounds through a route where they are not in contact with other care home residents – this should be supported where safe and possible given its importance in rehabilitation and to minimise the deconditioning impact of isolation

Individuals who test positive for COVID-19 should take part in daily lateral flow testing from day 5 (counting the day of the original positive test as day 0). They can end isolation after receiving 2 consecutive negative tests 24 hours apart, or after 10 days’ isolation. Any individual who is unable to test should be isolated for the full 10 days following a positive test. Isolation should only be stopped when there is an absence of fever (less than 37.8°C) for 48 hours without the use of medication.

Support caring for care home residents who test positive for COVID-19

Consideration should be given to having a smaller number of workers dedicated to supporting the person during their infectious period.

Pulse oximeters will be available to care homes through their named clinical lead, or local integrated care board (ICB), as part of COVID oximetry at home. One oximeter per 10 beds with a minimum of 2 oximeters per home is recommended. Equipment which is used to support the monitoring of residents will need to meet infection control and decontamination standards and guidance.

The Care Provider Alliance has produced guidance on COVID oximetry at home. Health Education England and West of England AHSN have also produced training and support for care home staff using pulse oximetry.

Care homes should have a weekly check-in with the home’s PCN or multidisciplinary team, who can support staff to understand the RESTORE2 and NEWS2 scoring system as a way of monitoring residents with symptoms. If a patient’s symptoms worsen, it is important to contact NHS 111 or the registered GP for a clinical assessment either by phone or face to face.

The resident’s GP should give further advice on escalation and ensuring decisions are made in the context of the resident’s advance care plan. In a medical emergency, the care home should dial 999.

Visiting arrangements in care homes

Access inside the care home

Contact with relatives and friends is fundamental to care home residents’ health and wellbeing and visiting should be encouraged. There should not normally be any restrictions to visits into or out of the care home. The right to private and family life is a human right protected in law (Article 8 of the European Convention on Human Rights). In the event of an outbreak, each resident should be able to have one visitor at a time inside the care home. This visitor does not need to be the same person throughout the outbreak. They do not need to be a family member, and could be a volunteer or befriender.

It is important that any visitor follows the IPC processes put in place by the care home, such as practicing hand hygiene and wearing appropriate PPE. Please see the section on outbreak handling for further details on flexibility in visiting arrangements during outbreaks, such as for end of life visits.

Visitors should not enter the care home if they are feeling unwell, even if they have tested negative for COVID-19, are fully vaccinated and have received their booster. Transmissible viruses such as flu, respiratory syncytial virus (RSV) and norovirus can be just as dangerous to care home residents as COVID-19. If visitors have any symptoms that suggest other transmissible viruses and infections, such as cough, high temperature, diarrhoea or vomiting, they should avoid the care home until at least 5 days after they feel better.

Precautions for visitors

Visitors should be encouraged to wear a face mask when visiting a care home, particularly when moving through the home. Individual approaches may be needed as the wearing of face masks may cause distress to some residents. In circumstances where wearing a face mask causes distress to a resident, face masks may be removed when the visit is not in a communal area of the care home. Removal of the mask in non-communal areas may also be considered following a risk assessment if it is hindering communication, or in the case that the visitor is eating or drinking. However, other mitigations should be considered, including limiting close contact, increased ventilation (while maintaining a comfortable temperature) and transparent face masks. For more information on transparent face masks, please see the section above on face masks.

Some residents may need support with personal care from a visitor with whom they have a close relationship. This may include activities such as supporting someone with washing, bathing or cleaning themselves, getting dressed or going to the toilet.

Visitors providing personal care to residents are no longer required to test before visiting a care home. However, care homes should ask all visitors to wear face masks, in addition to other PPE if they are providing personal care, to ensure visits can happen safely. This should be based on individual assessments, taking into account any distress caused to residents by use of PPE or detrimental impact on communication.

Children under the age of 11, who are visiting a care home, may choose whether to wear face masks. However, they should be encouraged to follow the IPC guidelines such as practising hand hygiene.

Care home residents should not be asked to isolate or take a test following high-risk visits out of the care home including following emergency hospital stays (unless the hospital is in active outbreak – in which case, follow the advice above on discharge from hospital into a care home).

Visiting professionals

Health, social care and other professionals may need to visit residents within care homes to provide services. Visiting professionals should follow the same advice as in the section above on visiting precautions. PPE usage is recommended in line with guidance above. NHS staff and Care Quality Commission (CQC) inspectors also have access to symptomatic testing and should follow the same guidance as staff about staying away from work if they test positive.

Outbreak management

Outbreak handling

An outbreak consists of 2 or more positive (or clinically suspected) linked cases of COVID-19, within the same setting within a 14-day period (this means where the cases are linked to transmission in the care setting). This applies to both staff and residents and includes PCR and lateral flow test results

If an outbreak is suspected, the HPT (or community IPC team, local authority or ICB, according to local protocols) should be informed. A risk assessment should be undertaken with the HPT or other local partner to see if the clinical situation can be considered an outbreak and if outbreak management measures are needed.

If an outbreak is declared as a result of the risk assessment then measures will be taken. These will include testing and may also include: 

• temporarily stopping or reducing communal activities 
• closure of the home to further admissions 
• restriction of movement of staff providing direct care to avoid ‘seeding’ of outbreaks between different settings
• proportionate changes to visiting: some forms of visiting should continue if individual risk assessments are carried out. One visitor at a time per resident should always be able to visit inside the care home
• this number can be flexible in the case that the visitor requires accompaniment (for example if they require support, or for a parent accompanying a child). End-of-life visiting should always be supported and testing is not required in any circumstances for an end-of-life visit

Any implemented measures must be proportionate, and risk based. In specific situations, where the local or national risk assessment indicates that cases may be caused by a variant with vaccine escape potential or other concerns, additional measures may be advised.

In the event of an outbreak in a care home, outbreak restrictions will be in place for different lengths of time, depending on the characteristics of the home, the outbreak and the results of outbreak testing.

Outbreak testing

For information on testing in an outbreak and outbreak recovery testing, please see the adult social care testing guidance.