Coronavirus in care settings

What is coronavirus and what can care providers do to keep their service users and staff safe? This article provides a round-up of essential information for care settings, including PPE, testing, high-risk individuals, visiting and social distancing.

What is coronavirus?

The World Health Organization (WHO) defines coronaviruses as a family of viruses that cause infectious illness ranging from very mild to very severe diseases such as Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV). Covid-19 is a new strain which originated in China at the end of 2019. It has since spread worldwide, initiating a global pandemic public health emergency.

How does coronavirus spread?

People can catch Covid-19 from others who are infected.

The virus moves from person-to-person in droplets from the nose or mouth which are spread when a person with Covid-19 coughs or exhales. In addition, the virus can survive for up to 72 hours out of the body on surfaces. People can become infected if they breathe in the droplets or touch infected surfaces and then touch their eyes, nose or mouth.

The incubation period of Covid-19 is believed to be between 2 and 10 days. This means that if a person remains well 10 days after contact with someone with confirmed coronavirus, they have likely not been infected.

What are the symptoms?

The NHS recognise the main symptoms of coronavirus as:

  • fever and high temperature — people will feel “hot to touch” on their chest or back (37.8ºC or above)

  • new, continuous dry cough — the NHS define this as coughing a lot for more than an hour, or three or more coughing episodes in 24 hours (someone with an existing cough may find that it is worse than usual)

  • loss or change to the sense of smell or taste — the NHS defines this as someone noticing that they cannot smell or taste anything, or things smell or taste different to normal.

Most people with coronavirus have at least one of these symptoms. Other less common symptoms include aches and pains, nasal congestion, headache, conjunctivitis, sore throat, diarrhoea, or a skin rash or discolouration of fingers or toes.

Symptoms begin gradually and are usually mild. Most people (about 80%) recover from the disease without needing special treatment. A small percentage can become seriously ill and develop difficulty breathing. This is particularly dangerous for people with weakened immune systems, for older people, and for those with long-term conditions such as diabetes, cancer and chronic lung disease.

How can people protect themselves?

Public Health England (PHE) recommends that the following general “handwashing and respiratory hygiene” precautions are taken to help prevent spreading coronavirus.

  • Cover the mouth and nose with a tissue or sleeve (not hands) when coughing or sneezing (Catch it. Bin it. Kill it).

  • Put used tissues in the bin straight away.

  • Wash hands regularly with soap and water for at least 20 seconds — use hand sanitiser gel if soap and water are not available.

  • Try to avoid close contact with people who are unwell.

  • Clean and disinfect frequently touched objects and surfaces.

  • Do not touch eyes, nose or mouth if hands are not clean.

In addition, the Government is asking people to “self-isolate” if they have symptoms of Covid-19, to stay at home whenever possible and to “socially distance” themselves.

What is self-isolation?

Self-isolating is a key element in fighting the pandemic. It is understood that most people will no longer be likely to transmit the virus 10 days after the onset of symptoms. Self-isolation is therefore designed to slow down the spread of the virus and protect others whilst someone may be infectious.

People should stay at home and self-isolate as follows:

  • those who have symptoms of infection and live alone should self-isolate by staying at home and not leaving their house for 10 days from when the symptoms started — they should arrange for a test to confirm that they have Covid-19

  • those who test positive for coronavirus should continue to self-isolate for 10 days from onset of symptoms, or 10 days from point of taking a positive test if they are asymptomatic — those who test negative can stop self-isolating as long as they are well

  • those who live with others and one person has symptoms should self-isolate as a household for 14 days from the day when the first person in the house became ill (if anyone else in the household starts displaying symptoms, they need to stay at home for 10 days from when the symptom appeared, regardless of what day they are on in the original 14-day isolation period)

  • those who have been in contact of a person who has had a positive test result must self-isolate at home for 10 days from the date of their last contact.

People who are contacted by NHS Test and Trace must follow isolation guidance provided by contact tracers.

Those who are symptomatic are advised to:

  • stay at least two metres (about three steps) away from other people in the home whenever possible

  • sleep alone, if possible

  • wash hands regularly for 20 seconds, each time using soap and water

  • stay away from vulnerable individuals, such as the elderly and those with underlying health conditions as much as possible

  • keep hydrated and use over the counter medications, such as paracetamol, to help with the symptoms.

If symptoms worsen during home isolation, or if they are no better after seven days, they should contact NHS 111 online. If without internet access, they should call NHS 111. For a medical emergency they should dial 999. Those who are worried about their symptoms should avoid going directly to their GP, to a pharmacy or to a hospital.

People should plan ahead and ask others for help to ensure that they can successfully stay at home. Where necessary, they should ask employers, friends and family to help them get the things they need.

Stay at Home: Guidance for Households with Possible or Confirmed Coronavirus (COVID-19) Infection, published by Public Health England, contains further advice.

National alert levels

The lockdown and requirement for social distancing has been informed by an alert level system introduced by the Government in May.

There are five levels.

  • Level five (red) signifies a "material risk of healthcare services being overwhelmed" and requires extremely strict social distancing.

  • Level four signifies “a high or rising level of transmission” and requires enforced social distancing.

  • Level three (amber) describes the virus as being “in general circulation” but no longer high or rising exponentially — as a result social distancing can be relaxed.

  • Level two describes the number of cases and transmission as being low — minimal social distancing is required.

  • Level one (green) will describe a situation where Covid-19 is no longer present in the UK and social distancing will no longer be required.

The Joint Biosecurity Centre (JBC) has the task of recommending what the alert level should be.

Estimating the alert level involves calculation of an “R” value by public health experts. This value reflects the average number of people that a single person might infect on a daily basis.

The R value is typically expressed as a range. Therefore an R number between 1.1 and 1.3 means that on average every 10 people infected will infect between 11 and 13 other people. A growth rate between +2% and +4% means the number of new infections is growing by 2% to 4% every day.

The Government has stated that it wishes to keep the R value as close to 1 as possible. This means that the virus is not spreading and has been effectively suppressed.

Covid-19 public health restrictions

The Government response throughout the Covid-19 pandemic has been to take necessary public health action to limit transmission of the virus by imposing a series of restrictions whenever the R number has grown too high and the alert level has had to be raised. These restrictions have included:

  • regional and national lockdowns requiring people to stay at home, including working from home wherever possible

  • people observing “social distancing” when they do leave home, keeping at least two metres away from others not in the same household

  • restrictions on travel, especially trips in and out of lockdown areas and international travel

  • restrictions on gatherings and closures of places such as pubs, restaurants, cafes, schools and hairdressers

  • “shielding” for the most vulnerable members of society.

The restrictions have been supported by legal enforcement, including spot fines for transgression. In addition, mask wearing has become mandatory in many indoor areas and on public transport and has become commonplace elsewhere as people have grown to accept the restrictions and protect themselves.

It should be noted that, while they have worked closely together throughout the pandemic, different rules have been applied in England, Northern Ireland, Scotland and Wales and the pattern of restrictions have varied from place to place.

After a brief summer respite, at the end of 2020 a “second wave” of infection swept through Europe and the UK as people moved indoors in colder weather and new more infectious Covid-19 variant strains emerged. These included a “Kent” strain (B117) and a virulent strain from South Africa.

Public Health England has stated that any resultant illness from these coronavirus mutations appears to be no more severe. However, the variants are estimated to be up to 70% more transmissible than original strains of the virus, raising the “R value” dramatically and spreading rapidly.

As the NHS came under severe pressure the national alert level was raised to Level 5 over the 2021 new year period and another strict lockdown was put in place throughout the UK to halt the spread of infection. The lockdown was considered necessary despite the hopeful sign of vaccines becoming available and being rolled out across the country.

National Lockdown: Stay at Home lists the full range of restrictions.

Roadmap out of lockdown

On 24 February the Government in England published a roadmap for coming out of the January 2021 lockdown. They announced that transmission rates were once again dropping and, despite the NHS remaining under serious pressure, a very cautious relaxation can now be contemplated. The plan is based on an ambitious target for Covid vaccination which is showing signs of being effective in helping to control the virus.

According to Stage 1 of the plan, by 8 March provisions will include:

  • all schools and colleges will reopen with face coverings recommended in class for secondary school students and also for parents and staff in primary schools — outdoor after school sports will be allowed

  • university students returning for practical courses

  • wraparound childcare available for vulnerable pupils and where it is needed for parents or carers to go to work or to seek medical care

  • care home residents will be allowed one nominated person to be able to visit them indoors and with whom they can hold hands — visitors will need to wear appropriate PPE, take a lateral flow test and “keep physical contact to a minimum”

  • two people from different households will be able to meet outside for recreation, which can include “a coffee on a bench”.

From 29 March:

  • people will be allowed to meet outside, either with one other household or within the “rule of six”, including in private gardens

  • the stay at home rule will end, but the Government will urge people to stay local as much as possible

  • outdoor sport facilities will reopen, including golf courses and tennis and basketball courts

  • parents and children groups can return but these must be outside and capped at 15

  • formally organised outdoor sports can also restart.

In Stage 2, no earlier than 12 April:

  • shops, hairdressers, beauty salons, gyms and spas will be allowed to reopen

  • restaurants and pub gardens will be allowed to serve customers sitting outdoors, including alcohol

  • domestic UK holidays will be permitted, with self-contained accommodation able to reopen for use by members of the same household

  • children will be allowed to attend indoor play activities, with up to 15 parents or guardians allowed to join them.

In Stage 3, no earlier than 17 May:

  • people will be able to meet in groups of up to 30 outdoors and six people or two households can meet indoors

  • pubs, restaurants and other hospitality venues will be able to seat customers indoors and hotels, hostels and B&Ss will be able to reopen

  • indoor entertainment such as museums, theatres, cinemas and children's play areas will be able to open

  • adult indoor group sports and exercise classes will restart.

Lastly, in Stage 4, no earlier than 21 June, it is hoped that all legal limits on social contact will be removed and there will be no legal limits on the number of people who can attend weddings, funerals and other life events.

It should be noted that the estimated dates between roadmap stages are provisional and may be subject to change as the recovery from the pandemic progresses. Full details are set out in Covid-19 Response — Spring 2021. Each stage will be a minimum of five weeks apart and will depend upon the ongoing rollout of vaccination and no surge in hospital admissions. The programme will be kept under review and adjusted as required.

There will be variations in the exact nature of timings and conditions in Scotland, Wales and Northern Ireland. However, the general direction of travel is broadly the same with an emphasis on a return to schooling for children.

“Moderate-risk” and “high-risk” individuals

Since the start of the pandemic, Public Health England has recognised two categories of people who are considered to be more at risk of serious illness from Covid-19 infection than others, those who are at moderate risk (vulnerable) and those who are at high risk (extremely vulnerable).

NHS guidance is available here.

Vulnerable (moderate-risk) people include those who:

  • are 70 or older

  • are pregnant

  • have a lung condition such as asthma, COPD, emphysema or bronchitis (not severe)

  • have heart disease, diabetes, chronic kidney disease or liver disease (such as hepatitis)

  • are taking medicine that can affect the immune system (such as low doses of steroids)

  • are very obese.

Extremely vulnerable (high-risk) people include those who:

  • have had an organ transplant

  • are having chemotherapy for cancer, including immunotherapy

  • are having an intense course of radiotherapy for lung cancer

  • have a severe lung condition (such as severe asthma or severe COPD)

  • are taking medicine that makes them much more likely to get infections (such as high doses of steroids)

  • have a serious heart condition and are pregnant.

Since the start of the pandemic, those in the “moderate-risk” (vulnerable) category have been advised to be cautious and stay at home as much as possible. They can go to work if they cannot work from home but should be very careful to comply with social distancing and handwashing advice.

During the height of the pandemic those in the “high-risk” (extremely vulnerable) category were made subject to special “shielding” arrangements. This involved people being advised to self-isolate and not to leave home for any reason wherever possible.

As part of the general lockdown easing process, the need for shielding was re-evaluated and in August the scheme was paused. As with people at moderate risk, shielded individuals were free to return to a Covid-safe workplace, if they could not work from home, and to go out for shopping and exercise. However, they were advised to be careful in taking precautions.

With the emergence of the more transmissible coronavirus strains in the UK, shielding was reinstated in December and individuals once again advised to not go out (except for exercise and medical appointments) and to keep contact with others to a minimum. The advice runs until the end of March.

In February 2021, following a greater understanding by doctors of the importance of factors such as age, ethnicity and deprivation, more people were written to and added to the shielding list.

The Government webpage Guidance on Shielding and Protecting People Defined on Medical Grounds as Extremely Vulnerable from COVID-19 has been kept updated as the pandemic has progressed.

Care home guidance

Admission and Care of Residents in a Care Home During COVID-19 was published by PHE in collaboration with the Care Quality Commission at the start of April. This replaced the earlier COVID-19: Guidance on Residential Care Provision. Version 2 was published in June and has been kept updated.

The guidance covers:

  • admitting new residents

  • caring for residents with Covid-19

  • reporting Covid-19 cases

  • providing care after death

  • resilience, including advice on staff self-isolation and staffing shortage

  • supporting existing residents who may require hospital care.

The most recent update was produced in December 2020 and included new guidance on isolation and testing.

The guidance states that care providers should follow all relevant government guidance for everyone in a care home. For example, wherever possible, care homes should be implementing social distancing measures and supporting individuals to follow the shielding guidance for the clinically extremely vulnerable group.

Any resident presenting with symptoms of Covid-19 should be promptly isolated and tested. Staff should immediately instigate full infection control measures to care for the resident.

PHE advises that all residents being discharged from hospital or interim care facilities to a care home, and new residents admitted from the community, should be isolated for 14 days within their own room. This should be the case unless they have already undergone isolation for a 14-day period in another setting. Even then, PHE states a care home may wish to isolate new residents for a further 14 days.

A 14-day period of isolation is being recommended for residential settings as older care home residents are a particularly vulnerable group and their immune response may differ from younger, normally healthier individuals.

Advice for staff contains the strong recommendation that, given evidence of the chances of asymptomatic transmission, care homes should do all they can to restrict staff movement wherever feasible. This includes ensuring that members of staff work in only one care home, wherever possible. Providers are also advised to consider “cohorting” staff to individual groups of patients or floors/wings.

A number of annexes contain further details for providers on minimising risks.

For example, Annex D describes standard infection prevention and control (IPC) procedures and Annex E covers restrictions for workforce movement. Annex F covers the availability and use of personal protective equipment (PPE). It includes links to further PPE information. Annex I describes the use of the “Capacity Tracker” which is used to support discharge planning by tracking care home vacancies.

A detailed annex on isolation (Annex C) states that all symptomatic residents should be immediately isolated for 14 days from onset of symptoms. Wherever possible they should be looked after in single occupancy rooms with en-suite facilities. Where this is not practical, symptomatic residents may be cared for together in multi-occupancy rooms. The guidance specifies that residents with suspected Covid-19 should be cohorted only with other residents with suspected Covid-19. They should not be cohorted with confirmed cases.

Signage should be displayed to prevent unnecessary entry into any isolation room. Doors should be kept closed. Staff should immediately instigate full infection control measures and wear appropriate PPE to care for any resident with symptoms.

Annex G covers decontamination and cleaning processes for care homes with possible or confirmed cases of Covid-19.

Annex J provides detailed guidance on Covid-19 waste management measures. The guidance states that non-healthcare waste, eg recycling, domestic type waste, packaging, etc must continue to be handled and managed as normal. It also advises the following options for personal contact or “respiratory intervention” waste from someone with suspected or confirmed Covid-19 infection.

  • Place in a “tiger bag” — a yellow bag with a black stripe — and store securely for 72 hours before placing in usual waste collection.

  • If not possible to store securely for 72 hours, place in an orange bag and dispose of as infectious clinical waste.

In the latest addition, Annex K provides information on testing individuals moving from the community into a care home.

Home care guidance

Coronavirus (COVID-19): Provision of Home Care was published by PHE on 22 May to replace earlier guidance.

The guidance states that if anyone being cared for by a home care provider reports developing Covid-19 symptoms they should be supported to contact NHS 111 via telephone, or online. Home care workers are advised to report suspected cases of Covid-19 to their managers who should work with community partners, commissioners and the person involved to review their care needs.

A considerable part of the PHE guidance concerns advice on dividing service users into “care groups” where a specific staff team is allocated to provide care to each. Thus “high-risk” shielded service users might be placed in one group and their care provided by a certain cohort of staff, reducing the risk of virus transmission to a minimum.

The guidance states that home care providers should be working with other agencies to reduce the risks for shielded individuals still further. This might be through identifying priority needs and coordinating care packages.

Where it is not possible to allocate specific care groups to specific staff subgroups, PHE suggests that it may be possible to schedule for shielded and at-risk individuals to be seen before people from other categories. PHE states that risks can also be reduced by reducing contact between staff, including replacing face-to-face meetings with remote communications, and by staggering times of entry to community bases.

The guidance provides further advice on:

  • hospital discharge and testing — including testing for home care workers and individuals receiving home care and testing for patients being discharged from hospital into the community

  • trusted assessor schemes — schemes to aid safe and timely discharges to care homes and care at home services

  • government and NHS support for social care

  • steps for local authorities to support home care provision.

Separate guidance covers personal assistants employed using direct payments from personal health budgets. This can be found here.

PPE

Guidance on the wearing and management of personal protective equipment (PPE) is contained in the following PHE documents.

The guidance covers periods of “sustained transmission” when the Covid-19 virus is considered to be widespread in the community and likely to be encountered. It describes safe ways for working for all adult social care workers and includes helpful FAQs to cover most situations that staff will face.

The resource for workers in care homes states that, when providing personal care which requires staff to be in direct contact with residents (eg touching, bathing, washing, etc) or requires them to be within two metres of any resident who is coughing, staff should use:

  • single-use disposable gloves

  • a single-use disposable plastic apron

  • a fluid-repellent (type IIR) surgical mask.

PHE states that eye protection may also be needed where there is risk of contamination to the eyes from respiratory droplets or from splashing of secretions. They state that single-use items should be changed between each episode of care, but that masks and eye protectors can be used “continuously” while providing care until the member of staff takes a break from their duties.

When within two metres of a resident, but not delivering personal care or needing to touch them, and where there is no one within two metres who has a cough, PHE recommends that only a type II surgical mask is required. A fluid-repellent mask is not needed. However, if one is already being worn during a given session, there is no need for it to be replaced.

The guidance was updated in July when a recommendation was added for staff in any other situation when in a care home to wear a mask. It applies to staff in any role working in staff only areas, such as staff common rooms, offices, laundry rooms, kitchens, etc. Staff working alone in a private area are exempt. However, they are required to wear a mask if they leave the private work area to move through the care home building, eg on an errand, or for meal breaks.

The document is accompanied by a video guide, Putting on and Removing PPE — a Guide for Care Homes.

The PPE resource for domiciliary care workers sets out similar guidance to that provided for care homes.

Home care workers are advised to wear disposable gloves, a disposable plastic apron and a fluid-repellent surgical mask whenever providing personal care which requires them to be in direct contact with a client (eg touching) or where they are within two metres of anyone in a household who is coughing. The recommendations apply whether the client being cared for has symptoms or not, and includes all clients, including those in the “extremely vulnerable” group. PHE states that the principles are also suitable for extra-care housing schemes and live-in home care.

Eye protection may also be needed for care of some clients where there is risk of droplets or secretions from the client’s mouth, nose, lungs or from body fluids reaching the eyes (eg caring for someone who is repeatedly coughing or who may be vomiting).

When a visit does not require staff to touch a client but does need them to be within two metres of the client, the guidance states that they only need wear a surgical mask. Household members with respiratory symptoms should remain outside the room or rooms where the care worker is working.

As with care homes, staff working in any other work situation when in a client’s home are advised to wear a mask. This also applies to staff in any role when in premises such as domiciliary care offices or when working with other staff members. Care workers do not have to wear a mask when in their car alone.

In all cases the use of PPE should be supported by effective hand hygiene.

The guidance is accompanied by a pair of posters demonstrating how to put PPE on and take it off in service users’ homes.

Visiting care homes

The latest guidance on care home visits in England can be found in the Department of Health and Social Care publication Guidance on care home visiting. This updated guidance was introduced as part of government measures to cautiously emerge from the January 2021 national lockdown.

DHSC state that the “default position” should be that visiting must be supported wherever and whenever it is possible and safe to do so. In this respect they state that all care homes should offer the following from the 8 March.

  • Every resident should be able to nominate a “single named visitor” who will be able to enter the care home to see them for regular visits.

  • In-person visits for other friends or family members should be offered using Covid-safe arrangements such as outdoor visiting, substantial screens, visiting pods, or behind windows, etc.

  • Visits during exceptional circumstances, such as end of life should be offered at all times.

  • Residents with the highest care needs should be able to nominate an “essential care giver”.

  • Alternatives to visiting should be facilitated, such as phone and video calls.

The DHSC state that each “single named visitor” should be tested for the Covid-19 virus using rapid lateral flow tests before every visit. They must wear appropriate personal protective equipment (PPE) and follow all other infection control measures (which the care home should guide them on) during visits. The visitor may hold hands with the resident they are seeing if they wish to. However, they should keep physical contact to a minimum and at this stage there must not be close physical contact such as hugging.

The concept of “essential care givers” is that some residents have care and support needs that include tasks which cannot easily be carried out by a member of staff (or not without causing substantial distress). A family member, or another intimate person, is required instead and should be allowed to visit to provide the additional care needed. The assumption by DHSC is that there will only be one essential care giver for one resident. However, exceptions may be agreed subject to the assessment of individual circumstances.

End of life visiting should be enabled at all times (including in the event of an outbreak) and families and residents should be supported to plan visits. The guidance states that this does not only mean in the “very end” of life.

During national lockdown periods visits have typically been limited to those that could be conducted outside in the open air, wherever possible, with visitor and resident remaining at least 2 metres apart at all times. Many homes have constructed or adapted special outside visiting facilities or “pods” — outbuildings with plastic or glass barriers or screens between residents and visitors. Use of these facilities should continue as this allows residents to see a greater number of people safely. However, spaces should only be used by one resident and visiting party at a time and should be subject to regular cleaning.

All visiting must happen within a wider care home environment of robust infection prevention and control (IPC) measures and management of risks. Providers should set out their visiting arrangements in a suitable policy which has been developed in collaboration with residents and families. The policy should be based on a “dynamic” risk assessment that is regularly reviewed and informed by advice from local directors of public health and public health teams. Alternatives to visiting, such as keeping in touch through phone and online video links, should be supported wherever possible.

Critically, DHSC state that in the event of a Covid-19 outbreak in a care home, the home should immediately stop visiting.

Visitors should be tested using supplied lateral flow devices (LFD) according to government advice, Care home LFD testing of visitors guidance.

Note that the rules relating to care home visits differ in other parts of the UK.

In Scotland Open with Care — supporting meaningful contact in care homes: guidance applies. This states that routine indoor visiting of care home residents by relatives, friends and carers will be able to resume from early March with care providers supporting residents to have up to two designated visitors each and one visit a week for each visitor.

In Wales Visits to care homes: guidance for providers (Version 4) applies.

Staff health and wellbeing

Health and Wellbeing of the Adult Social Care Workforce was published by the Department for Health and Social Care on 11 May. The document recognises the “dedication and commitment” shown by care workers and care organisations during the Covid pandemic. It also recognises the costs, especially for staff who may also have families to support and high-risk dependents. Examples of costs include worry and anxiety.

The guidance includes tips, advice and toolkits that social care employers and managers can use to help build the resilience of their teams and address any concerns their staff may have.

In both residential care and home care, any member of staff who is concerned that they may have Covid-19 should stay at home and follow Government advice for self-isolation. They should not attend for work or see service users.

Government support for adult social care

The Government has developed a range of support mechanisms for the adult social care sector. The support schemes recognise the importance of the sector and the pressures that managers and staff are under.

COVID-19: Our Action Plan for Adult Social Care recognises difficulties in obtaining enough PPE and sets out action to tackle this. It also promises more support to tackle outbreaks in care homes and a safer system of discharge from hospitals. Lastly, to support those working in the sector, the plan refers to an expansion in Covid-19 testing for adult social care staff and care home residents.

The action plan is backed by a support package for care homes which includes the following.

  • Infection control training — including “train-the-trainers” courses from infection control nurses.

  • A number of schemes to improve the supply of PPE — including PPE distributed specifically for care homes through Local Resilience Forums.

  • An infection control fund intended to help providers pay for additional staff and /or maintain the normal wages of staff who, in order to reduce the spread of infection need to reduce the number of establishments in which they work, reduce the number of hours they work, or self-isolate.

  • £1.6 billion in March 2021 and a further £1.6 billion in April to support providers in meeting pressures across the range of public services.

  • £1.3 billion Covid-19 discharge funding via the NHS to support local authorities to provide alternative accommodation to quarantine and isolate residents before their return to their care home, if required.

  • Increased clinical support from local primary care and community health services — including a named clinical lead for every care home, weekly “check-ins” and support for the use of key medical equipment such as pulse oximeters.

Details are published in Coronavirus (COVID-19): Care Home Support Package.

Testing, tracing and tracking

A nasal/throat swab test is available to confirm the presence of the virus. Such testing is seen as a key element in combatting the virus and keeping people safe.

In the early stages of the pandemic, tests were restricted to those in hospital. However, testing capacity has been drastically scaled up to enable tests to be conducted of all essential workers, including NHS and social care staff, and of symptomatic and asymptomatic care home residents. In addition, the Government have confirmed that all people discharged from hospitals to care homes will be tested.

Latest details can be found in the online government document, Coronavirus (COVID-19): Getting Tested.

The guidance states that the following groups are eligible for testing through the NHS.

  • Anyone in England and Wales who has symptoms of coronavirus, whatever their age.

  • Anyone in Scotland and Northern Ireland aged five and over who has symptoms of coronavirus.

The following groups can access priority testing.

  • Essential workers in England, Scotland, Wales and Northern Ireland.

  • Anyone in England, Scotland, Wales and Northern Ireland over five years old who has symptoms of coronavirus and lives with an essential worker.

  • Children under five years old in England and Wales who have symptoms of coronavirus and live with an essential worker.

Care staff are regarded as essential workers throughout the UK.

Tests can be arranged through the NHS website using one of the following routes.

  • A staff self-referral route.

  • An employer referral route for staff who are self-isolating.

  • A “whole home” referrals route which allows care home managers to arrange testing for all of their staff and residents.

Tests for staff and their families can be performed in regional drive-through centres or using home testing kits. “Whole home” tests use kits sent to the home and collected by a courier. Details of the online referral portals and the exact application and referral processes involved can be found in the guidance.

Two types of test kits are delivered to care homes:

  • polymerase chain reaction (PCR) test kits (Kingfisher kits)

  • lateral flow device (LFD) test kits.

The guidance states that PCR test kits should be used to test staff members weekly and residents every 28 days. LFD tests should be used to test staff on their first day back to work following a period of leave that has resulted in someone missing their weekly PCR test. In this case staff should be tested before they begin their shift.

LFD tests should also be used to test visitors and visiting professionals.

In the event of a suspected outbreak of Covid-19 in a care home, the manager concerned should contact their local health protection team who will arrange any action required, including testing.

Contact tracing is an established infection prevention technique that has long been used in combatting communicable diseases such as coronavirus. It involves identifying and isolating people who are infected and then tracing those who may have been in contact with them. These people can then be tested and isolated as required.

Inspections

In March, during the initial crisis stage of the Covid-19 pandemic, the Care Quality Commission (CQC) announced a temporary pause to inspections in England. An Emergency Support Framework (ESF) was developed to respond to the changing needs of the health and social care system during the pandemic period. This went live at the beginning of May and was designed to help the CQC identify problem areas and target support.

In September, the CQC announced that it was turning its attention to how it would regulate the health and social care sectors during the next phase of the Covid-19 pandemic. They have stated that they are not returning to any fixed timetable of regular scheduled inspections yet. Instead they will be using their “insight” model to monitor providers during a “transitional” period and reinstate targeted inspections for higher risk services. Where site visits are needed inspectors will adopt a “balanced” approach to limit any risk of spreading infection.

In addition to their regulatory activity the CQC has also conducted a review of infection prevention and control (IPC) systems in residential social care. To support this review the CQC have developed a new IPC inspection tool with updated and expanded key lines of enquiry. The tool can be used by providers who wish to strengthen their IPC processes and arrangements. It can be found on the CQC website.

Travel advice

Travelling is now much reduced due to countries around the world closing their borders to protect themselves against different strains of coronavirus being introduced into the country by international travellers. Government advice during the national lockdown is that people must not leave home or travel, including internationally, unless they have a legally permitted reason to do so.

Those that do travel are subject to a number of restrictions and rules.

From 18 January 2021, those who intend to travel to England, Scotland, or Wales, and UK nationals returning home from travel abroad, must provide evidence of a negative Covid-19 test result taken up to three days before departure. They must also self-isolate when they enter the UK from any foreign country except Ireland, unless they have a valid exemption.

Vaccine development and the future

Research into Covid-19 vaccines is being carried out as a priority all around the world, the hope being that a successful vaccine, in combination with more effective treatments for people who are infected with the virus, will be the quickest way to help return the world to some form of normality.

Vaccines developed by the drug companies Pfizer and BioNTech in the USA/Germany and by Moderna in the United States have both been shown to be about 95% effective, effectiveness being a measure of the vaccines ability to create an immune response and confer immunity against the Covid-19 virus. In the UK, a vaccine developed jointly by Oxford University and AstraZeneca has been developed which has a 70–90% effectiveness depending on the dose.

All three vaccines have been approved by the Medicines and Healthcare products Regulatory Agency (MHRA) for use in the UK and urgent plans for a national vaccination rollout devised. This begun in December and will progress through 2021 as a national priority.

A strategy setting out priority groups for the vaccination roll-out has been developed by the Joint Committee on Vaccination and Immunisation, Advice on Priority Groups for COVID-19 Vaccination. The JCVI is the expert advisory group responsible for making recommendations relating to all aspects of vaccination in the UK. According to the strategy, the most vulnerable must be vaccinated first, along with those that care for them. This includes care home residents and staff as the highest priority. People who are on a GP register for learning disabilities were added to the priority groups in an update to the schedule.

Details of the COVID-19 Vaccination Programme have been set out on the GOV.UK website. The webpage contains links to relevant documents such as:

  • COVID-19: the Green Book, Chapter 14a — containing details of both vaccines, precautions for use, side-effects, etc

  • COVID-19 Vaccination: Information for Healthcare Practitioners — containing details on the programme for GPs and other healthcare practitioners

  • COVID-19 Vaccination: Consent Forms and Letters for Care Home Residents

  • COVID-19 Vaccination: Guide for Older Adults — a public information leaflet

  • COVID-19 Vaccination: a Guide for Social care Staff – an information leaflet for staff

  • COVID-19 Vaccination: Care Home and Healthcare Settings Posters — including a poster for care homes

  • Priority Groups for Coronavirus (COVID-19) Vaccination — advice from the Joint Committee on Vaccination and Immunisation (JCVI) setting out the strategy for who should be vaccinated first

  • COVID-19 Vaccinations and Care Homes: Programme Launch — a letter to care home managers in England setting out how they should prepare for vaccinating their staff and residents

  • Training materials for staff involved in supporting the vaccination programme.

Care home managers should refer to the webpage for the latest versions of documents.

The NHS is mobilising a huge national effort to offer the vaccines. The Pfizer/BioNTech vaccine was initially delivered from a limited number of hospital hubs. This was because it needs to kept very cold. The AstraZeneca vaccine is easier to deploy and is being rolled out through hospitals, community vaccination centres, GP practices and “mass vaccination” hubs. During 2021 the availability will expand as supplies of the vaccines increase, with a growing number of sites offering vaccination.

Adult social care staff were targeted for vaccination in the first weeks of the campaign. The majority have now been offered vaccination. Care home residents are being offered vaccines by NHS and primary care staff visiting homes. An initial government target to offer vaccines by mid-February to the over-70s, to health and social care workers and to those required to shield — about 15 million people — was met. The rest of the priority groups will follow through to the spring. It is hoped that vaccines will then be available for the rest of the adult population and for all adults to have been offered a first vaccination by July.

The currently available vaccines require a two-dose course for maximum effectiveness against the virus. However, the JCVI strategy has been updated to place priority on promoting rapid, high levels of vaccine uptake amongst vulnerable persons. The JCVI thus state that delivery of the first dose to as many eligible individuals as possible should be initially prioritised over delivery of a second vaccine dose. JCVI therefore recommend that the second dose of the Pfizer/BioNTech vaccine may be given between 3 to 12 weeks following the first dose and the second dose of the AstraZeneca vaccine may be given between 4 to 12 weeks following the first dose.

Public health doctors have been quick to welcome the development of the new vaccines as an exciting breakthrough in the fight against Covid-19. However, they warn that there is still a long way to go. A national vaccination roll-out during 2021 on the scale that will be needed is a huge undertaking and will take many months. In the meantime, tried and tested methods of preventing virus transmission, such as social distancing and the wearing of masks, must continue.

Flu Immunisation

Winter pressures in the NHS and in the social care sector include those caused by flu. For the 2020–21 flu season the pressures are increased by the dangers of influenza and coronavirus co-circulating. Adult social care providers should therefore ensure that their flu management policies are in place and that they make all necessary arrangements to encourage staff and service users to get immunised.

This year the key priority groups eligible for the flu vaccine include:

  • people aged 65 years or over

  • those aged 6 months to under 65 years in clinical risk groups, such as those with chronic (long-term) respiratory disease, liver or heart disease

  • people living in long-stay residential care homes or other long-stay care facilities where rapid spread is likely to follow introduction of infection and cause high morbidity and mortality

  • those who are in receipt of a carer’s allowance, or who are the main carer of an older or disabled person whose welfare may be at risk if the carer falls ill

  • household contacts of those on the NHS Shielded Patient List for the coronavirus

  • health and social care workers employed through Direct Payment (personal budgets) and/or Personal Health Budgets, such as Personal Assistants, delivering domiciliary care to patients and service users

  • health and social care staff.

NHS England state that they aim to further extend the vaccine programme to include the 50–64-year-old age group subject to vaccine supply.

Public Health England point out that those most at risk from flu are also among the most vulnerable to Covid-19, and if people get flu and coronavirus at the same time, they are more likely to be seriously ill.

See Flu Vaccination Guidance for Social Care Workers for more information.

Where can the latest information be found?

Care providers and managers should keep as up to date as possible and ensure that staff, service users and their relatives are kept informed.

The following official sources can be used.

People are warned to avoid misinformation and out-of-date information. Guidance has changed rapidly throughout the outbreak. It may also vary according to where in the UK people live. Always refer to the latest official Government information.

The National Institute for Health and Care Excellence (NICE) have published the first of a series of “rapid” coronavirus guidelines. Further guidelines are in development and will be published on the Covid-19 section of the NICE website.