CQC: infection, prevention and control in care homes
We previously introduced how we are looking at infection prevention and control (IPC) in care homes. We have now published our new IPC inspection tool on our website.
As we increase targeted and focused inspections of high risk services, this tool will be used to look at how well staff and people who live in the care home are protected by the prevention and control of infection (Key Line of Enquiry S5). Over time, we will look to improve and adapt the tool for other types of services.
The tool will help us to gather information about the strengths of a service and to understand if there are any gaps or concerns around IPC where we can signpost to resources which could help.
We all plan to manage any risk of a second wave of the coronavirus and the impact of winter pressures. This helpful tool is something you can use to prepare.
PPE in care homes
We currently remain in a period of sustained transmission. Requirements for PPE in care homes during sustained transmission are set out in: How to work safely in care homes.
The key general summary on PPE use is:
- When providing direct care (contact) or when within 2 meters of a symptomatic resident – full PPE (apron, fluid repellent surgical face mask, gloves) is required with a risk assessment around eye protection
- When within 2 meters of a resident who has no symptoms but not performing direct care (contact) or touching them, and there is no one within 2 metres who has a cough - fluid repellent surgical face mask
When working in communal areas where you may be within 2 meters of a resident on occasions - fluid repellent surgical face mask (note that all symptomatic residents should be isolated)
When you're 2 metres or more from a resident you should be wearing a Type I or Type II surgical mask. This includes staff not in a caring role e.g. cleaners, receptionists and when not in direct proximity to residents e.g. in staff only areas.
If you work alone in an office you will not be expected to wear a mask but when you leave the private work area to move through the care home building, e.g. on an errand, or for meal breaks, you should put on a surgical mask (Type I or II)
PPE in domiciliary care settings
This is assuming care workers are not undertaking aerosol generating procedures, information on that is below.
We currently remain in a period of sustained transmission. Requirements for PPE in domiciliary care settings during sustained transmission are set out in: How to work safely in domiciliary care
The key general summary on wearing PPE is:
- When providing personal care in direct contact with client – full PPE apron, fluid repellent surgical face mask, gloves) is required with a risk assessment around eye protection
- Whenin the client’s property but not performing direct care- wear a surgical mask
- Always risk assess the need to wear eye protection eg. When there is the potential for splash back.
- Where there is more than one client in the household , gloves and aprons will need to be changed between each episode of care
- Symptomatic patients could be asked to wear a surgical mask where tolerated.
- When you are within 2 metres of anyone in the household who is coughing, even if not providing care to them- full PPE (apron, fluid repellent surgical face mask, gloves) is required with a risk assessment around eye protection
- If you have been giving personal care to clients and you are changing your work duties e.g. going to your organisation’s office, then you need to remove your face mask, clean your hands and then put on a new Type l or Type ll face mask
- If you share workspace/working environment (e.g. including the office, staff communal areas and dining rooms) with care workers who care for clients then everyone in that workspace including yourself will need to wear a Type I or Type II face mask. If you do not share workspace or working environment with care workers who care for clients (e.g. if care workers are in a different office or part of building with no shared communal areas) then you do not need to wear a face mask. If you do work in a separate (e.g. private) office but share communal areas (e.g. dining room) with care workers then you would need to wear a Type I or Type II face mask in those communal areas.
• Sessional use refers to wearing masks and eye protection continuously until you take a break or the session ends (e.g. leaving one household)
• Where you need to remove your mask (e.g. to take a drink or eat) then you need to dispose of it safely. Do not dangle your mask or eye protection around your neck. Do not re-use your mask
• Where there is a shortage of FRSM FFP2 masks can be used; where there is an acute shortage of FRSM and FFP2 masks a non-fluid resistant mask can be worn with a full face visor.
This is assuming care workers are not undertaking aerosol generating procedures, information on that is below.
Aerosol Generating Procedures
Please be aware that that there are some aerosol generating medical procedures that might be in use in care homes and other community settings. These include CPAP and BiPAP machines, (sometimes used to treat the symptoms of sleep apnoea). There are additional PPE requirements that need to be considered in these circumstances where care is being provided to a person while they are using the equipment and up to an hour after it has been switched off.
These include the use of gowns and FFP3 masks. FFP3 masks must be fit tested to ensure an appropriate fit and training in the doffing and donning of PPE should be provided. If you are supporting someone who uses this type of equipment please contact the health care professional who is supporting the service user to discuss this further. If you have a service user using other equipment and you are not sure if this is aerosol generating again please contact the health care professional for clarification.
Public Health England provide a list of Aerosol Generating Procedures.
The current position of PHE is that suctioning of the oral cavity in front of the pharynx*, where you can still see the tip of the yankeur sucker or catheter does not constitute an AGP. If suction is past the pharynx, this could generate aerosols and although the risk is felt to be low it does constitute an AGP.
*The pharynx (plural: pharynges) is the part of the throat behind the mouth and nasal cavity, and above the oesophagus (food tube) and larynx.
If you feel you are conducting AGP’s your staff will need to be fit tested for safe use of FFP3 masks. You can contact the Quality Improvement Team at Pccg.firstname.lastname@example.org to discuss how this fit testing can be arranged.
Demonstration of donning and doffing PPE.
Skills for Care SE IPC WhatsApp Group and Weekly Webinar
The Infection Prevention and Control leads in the South East group aims to provide a forum where IPC leads can support each other, share resources and ask questions.
The network is open to:
- All staff who take responsibility for infection, prevention and control for their organisation. Each week, if questions have not been answered by the group and support from
- NHS/Improvement Team and Public Health England these are addressed at the weekly webinar.
If you would like to join the closed WhatsApp group and would like details for the Infection, Prevention and Control webinars please email your contact details, care organisation, mobile number to Debbie.email@example.com Skills for Care Locality Manager, Southampton, Hampshire, IOW and Portsmouth. Your details will not be shared with third parties.
Information about PPE supply
Over the last few months, the market regarding the provision of personal and protective equipment (PPE) has been very dynamic. In Portsmouth, mechanisms have been developed to support providers by ensuring that additional PPE purchases that you need to make because of the Covid-19 pandemic are reimbursed, and to provide emergency supplies.
We are now in a stable position in the city with stocks of PPE and supply lines, so we are keen to ensure that we provide the most efficient processes and best value for money for the city.
For these reasons, we would like to encourage providers to consider, when looking to purchase PPE for which you would otherwise submit a claim for reimbursement, to consider approaching PCC in the first instance for stocks, through the PPE@portsmouthcc.gov.uk inbox 'How to access PPE' guide using order form PPE order form
If you utilise the PCC stock, you will not need to submit a claim for reimbursement via ContrOCC. We carry as standard:
- Masks (Type IIR)
- Face visors and goggles
There are some items where there are still challenges in the market, and this includes gowns and FFP3 masks, which we are still struggling to secure, so for these items we will still only be able to support emergency supplies.
At all times, providers should continue to take advantage of other supply opportunities, including by using the national PPE portal and working with wholesalers where there are relationships or opportunities, for example, Wightman and Parrish who will supply to CQC registered addresses.
Please ensure that you regularly update the NHS Capacity Tracker with information about your PPE status. We use this information to help inform us of where to target our contact with providers to offer support.
Healthcare providers can order additional personal protective equipment (PPE) through the portal to top up their existing supplies for COVID-19 in an emergency.
Additional PPE support for care home providers
If you are a current customer of Wightman and Parish (W&P), you can call their Customer Service line (01323 445001) to place an order for gloves, up to 1000 units (1 case 10x100) per week. Wightman & Parrish also have a stock of aprons and masks that can be accessed where residents are showing symptoms of Covid-19 (see below).
You will need to be calling on a weekly basis as gloves cannot currently be accessed via the W&P website. All gloves will be delivered directly to settings, and cannot be sent to a central distribution centre.
If you are not a current customer of W&P, you cannot access this particular line of support, although other suppliers may put similar arrangements in place.
However, where a care home identifies they have residents with Covid 19 they can call the customer service number for W&P as they are an approved body under PHE. The care homes do not need to go through the PHE process and when they call W&P they will be taken through a list of questions about the current circumstances at the home before determining an allocation of gloves, aprons and masks.
Currently for each Covid patient in a home W&P will allocate sufficient stock i.e. 10 gloves, aprons and masks per day per resident. However, W&P will be looking at whether the care home has access to other stocks in determining whether they can supply additional equipment to these homes.
PPE Equipment Safety Information
Considerations for acute personal protective equipment (PPE) shortages
The World Health Organisation clearly states that each of these measures carries significant risks and limitations and thus should be considered only as a last resort when all other strategies for rational and appropriate use and procurement of PPE have been exhausted.
Further clarification on the guidance has been provided from local infection prevention specialists.
- In summary:
- This is not a business as usual option and should only be used when extreme shortages of supply occur
- Gloves and aprons are not to be re-used
- Eye protection (single use) can be re-used. The standard method of cleaning is to use a detergent product or combined product as agreed by local IPC specialists
- It is indicated that some facemasks could be re-used by carefully folding them so that the outer surface is held inward and against itself to reduce likely contact with the outer surface during storage, then storing the mask between uses in a clean sealable bag/ box which is marked with the person’s name and is then properly stored in a well-defined place. This guidance appears to relate to FFP2, FFP3 and N95 masks and not fluid repellent surgical facemasks.
- Fluid Repellent Surgical Facemask should continue to be:
- Any re-use of masks should clearly balance the risk of not having any mask to wear during direct care versus the risk of cross-infection.
- disposed of if they become moist, damaged, visibly soiled
- Used as sessional equipment - sessional use is dependent on local (e.g., heat, activity length, shift-length) and individual factors; in practice, this may vary from 2hrs up to 6hrs
- disposed of if the mask is removed for any reason (for example, upon exiting a COVID-19 area, taking a break, completing a shift).
Disposal of used PPE
Used PPE should be stored securely within disposable rubbish bags, placed into another bag and kept separate from other waste. This should be put aside for at least 72 hours before being put in the usual disposal bin.
Pressure damage from wearing PPE
Guidance for staff has been published around the prevention of facial skin damage beneath personal protective equipment (PPE). Advice includes:
- keeping your skin clean and well hydrated/moisturised
- applying creams at least 30 minutes before applying PPE (Caution: skin protectants and emollients with white soft paraffin are flammable. You are advised not to smoke with them present on your skin)
- Considering the use of a barrier skin wipe/skin protectant if you are likely to be wearing PPE for extended periods
- Taking time to fit your mask before starting a shift/procedure. Ensure all folds in your mask have been used to optimise the correct fit for you and do not over-tighten
- Regularly inspecting your skin for signs of redness/soreness
- Taking regular breaks (we recommend every two hours) from wearing a mask to relieve the pressure and reduce moisture build-up
- Staying well hydrated throughout the day.