COVID-19: Updated guidance for Supported Living (Updated 6 January 2021)

Who this guidance is for

This guidance is designed to update and build on the previous advice to supported living providers, which was withdrawn on 13 May 2020. It sets out:

• key messages to assist with planning and preparation in the context of the coronavirus (COVID-19) pandemic so that local procedures can be put in place to minimise risk and provide the best possible support to people in supported living settings. These local procedures may need to be updated to reflect changes in government guidance and advice as the pandemic response changes
• safe systems of working, including social distancing, respiratory and hand hygiene and enhanced cleaning
• how infection prevention and control (IPC) and personal protective equipment (PPE) applies to supported living settings

Although it is primarily intended for the managers, care and support workers, and other staff in supported living settings, it is also relevant to local authorities, clinical commissioning groups (CCGs), primary care networks (PCNs), and community health services. It will also be useful to read this guidance alongside the materials listed in Annex B.

Supported living enables adults to live in their own home – with the help they need to be independent – and allows them to choose where they want to live, who with, how they want to be supported, and what happens in their own home. As a term, it covers a wide variety of settings and may include some form of group living.

Homes may be shared between several people and have communal space or consist of separate units of self-contained accommodation – with or without communal space – but which may be located in shared buildings such as a block of flats and/or on shared grounds. Elements of supported living may be formally regulated by Care Quality Commission (CQC) and others not.

Supported living services involve tenure rights – renting or ownership, with associated occupancy rights. Some provide regulated ‘personal care’ and others support daily living activities such as help with shopping, food preparation, access to the community or a combination of both.

In some supported living models, it is not possible to defer the care and/or support provided to another day without putting people at risk of harm. It is therefore vital that these services are maintained.

The guidance is primarily for supported living settings, but many of the principles are applicable to extra care housing for older people. It may also be a useful resource for the wider supported housing sector, such as retirement or sheltered housing. Given the different types of supported living and the associated care, support and help for people living there, this guidance cannot be specific to individual locations, and local managers should use it to develop their own specific ways of working to protect people’s wellbeing and minimise risks.

Although this guidance is often worded as if the organisation’s management has full responsibility for accommodation as well as support and care services, ordinarily, care providers have no responsibility for property, accommodation or environment issues in supported living. In many instances, management’s role will be to develop local procedures and work with the people being supported and, with consent, their families, GP, support groups, and care/support providers to ensure that individual plans are in place to protect wellbeing and minimise risks.

In some instances, home modifications or adaptations may be required, for example to receive deliveries or to support reablement. Supported living is the person’s own home and, although advice and good practice may be offered, it will only be followed if the person understands the advice and is in agreement.

Some people being supported may lack capacity to understand and make decisions based on advice about the COVID-19 pandemic. It is important that all steps are taken to communicate information with people in a way that they are most likely to be able to understand. For example, autistic people and people with learning disabilities, dementia, or mental ill health may have difficulties with understanding complex instructions or forget them. This, and the other principles and requirements of the Mental Capacity Act 2005 (MCA) must be followed when it is felt a person being supported may lack capacity. Guidance and additional advice is available about the application of the MCA during the pandemic.

Steps that supported living providers and local authorities can take to maintain service delivery

To maintain service delivery, supported living providers and local authorities are advised to follow these steps.

1. Ensure that lists of people in supported living are up to date

Supported living providers and local authorities should work together to ensure that, where feasible, their lists of people in supported living are up to date. Lists should establish the levels of formal and informal care and support available to individuals.

Individuals should be supported to draw up a contingency plan – with their care providers and any unpaid carers – that can be enacted should they contract COVID-19 or there be an impact on care delivery due to COVID-19. Providers should consider how they could share this information.

2. Business continuity planning

Providers should have business continuity plans to help them to manage in emergency situations. These should be kept up-to-date and key details to record may include:

• who provides care for the people in supported living environments and whether these individuals are still able to provide care and are not shielding/self-isolating, whether paid staff or informal carers
• how and where care and support plans are located
• requirements for any specialist care and/or long-term conditions
• key contacts coordinating care from other community-based services including, but not limited to, mental health, learning disabilities, dementia, third sector Voluntary Social and Community Enterprises (VSCEs), drug and alcohol or social work teams, and family members

3. Key contingency details

Key contingency details should also include information about the person’s modes of communication including technology, their likely reaction to changes in routine or unfamiliar carers, and ways to reduce potential stress. In cases where current circumstances make consistency impossible, providers should prepare people for the fact that it may be necessary for a different carer to support them.

It is particularly important to ensure risk management plans are updated for people who may find any change in routine challenging, for example autistic people or people living with dementia.

4. Mutual aid, care and support plans

Providers and local authorities should work together to facilitate mutual aid, care and support plans across their areas. This is to inform planning ahead of a possible outbreak. Useful resources can be found on the Local Government Association website.

5. Identify people who use direct payments or fund their own support

Providers and local authorities should also work together to identify people who use direct payments or who fund their own support and help them establish the levels of support available from other providers or individuals.

It may be helpful for providers to share the number of hours of care they provide to help with planning, but they will want to satisfy themselves that it is lawful for them to share that information and get consent from the person where possible.

6. Avoid sharing staff between settings

Sharing staff between settings should be avoided to reduce the potential spread of COVID-19 from one setting to another. If a local risk assessment identifies service delivery issues caused by low staffing, then supported living and care/support providers can work with local authorities to establish plans for mutual aid, including limited sharing of the workforce.

Local primary and community health services providers may support with the deployment of volunteers and agency staff where that is safe to do so and provided safeguarding measures are in place.

7. Identify people who are clinically extremely vulnerable

Identify people who are clinically extremely vulnerable, and work with them, their families or advocates to explain issues related to guidance and make a joint decision on how they will be supported and on their accommodation and support needs. For example, when shielding advice is operational, a person who uses services may want to remain in their current home if they can be supported to ‘shield’ or they may wish/need to move to different accommodation that will enable them to ‘shield’ effectively.

8. Maintain oversight of people who are self-isolating

The supported living provider should maintain oversight of people who are self-isolating, and note the arrangements that local authorities, CCGs and NHS 111 are putting in place to refer people self-isolating at home to volunteers who can offer practical and emotional support.

By following these steps, most people who live in supported living environments should have a continuity of care, support and help that adapts to the situation with COVID-19. For a small number of people, where a person’s wellbeing is at risk, the managers of supported living environments may wish to contact social workers in their local authority to seek further advice and support.

Risk assessment, risk reduction and local implementation

A suite of guidance including responses to frequently asked questions has been published to support people in making decisions related to coronavirus (COVID-19) and many of these resources will be relevant to the supported living sector.

Providers will need to consider how to implement and risk assess these recommendations according to their individual circumstances and local operating models and may also wish to refer to IPC and PPE recommendations for:

• how to work safely in care homes
• how to work safely in domiciliary care
• admission and care of people in care homes

Updated guidance for homeless hostels has been developed. There is also guidance issued by Public Health England (PHE) for individuals, families and informal care workers for households with possible coronavirus infection.

Please note that this guidance is of a general nature and an employer should consider the specific conditions of each individual place of work and comply with all applicable legislation.

Staff within clinically vulnerable groups

Supported living settings are staffed by a wide range of people and some may be more vulnerable to infection, for example, because they have an underlying health condition. Staff whose health makes them clinically extremely vulnerable are recommended to follow the guidance on shielding and protecting clinically extremely vulnerable persons from COVID-19.

Factors including age, sex, ethnicity, certain underlying health conditions and/or pregnancy may be associated with an increased risk of or from COVID-19. Employers should ensure that an appropriate person, such as a line manager, carries out a risk assessment with all staff who may be at greater risk, in line with the latest guidance.

Staff from black, Asian and minority ethnic (BAME) backgrounds may have increased concerns about COVID-19, and employers should handle these conversations sensitively. Employers should ensure that staff are supported and any necessary steps to reduce risk are considered on an individual and proportionate basis. The employee should consult their employer if they have any concerns and discuss issues raised with their line manager.

Many staff will be able to work normally, while being particularly careful to follow social distancing measures.

General infection prevention and control

Infection prevention and control (IPC) measures include a hierarchy of controls designed to prevent harm and reduce transmission of infection to patients, residents, people who use supported living services, and health and social care staff and their co-workers.

To reduce the risk of COVID-19 spread and introduction into supported living facilities, measures should be followed including social distancing, hygiene principles (hand hygiene, sneezing or coughing into a tissue, safe disposal of tissues, following environmental cleaning regimes) and self-isolation (if a person or member of their household becomes ill with COVID-19 symptoms).

In addition to these core measures, PPE is required in specific scenarios, when social distancing is not possible, as described in the PPE section of this guidance.

Staff providing care for autistic people and people with dementia or learning disabilities should make every effort to make sure that the people they support are aware of the key behaviours needed to follow good IPC and should provide encouragement and reminders when not followed. Staff should consider how the person they are supporting is most likely to understand the information and use the most appropriate communication techniques for that person.

This may include the use of social stories, information in pictorial form, engaging with friends and family members to support understanding and having regular online contact with the person being supported, when it is not possible to see them face to face, to reinforce IPC messaging. Learning Disability England and PHE have created resources which may support this messaging.

Social distancing

The national advice on social distancing is to maintain 2 metres if at all possible. This is especially true in health and social care settings where the populations being cared for are vulnerable. Therefore, in this guidance document we recommend continuing to use 2 metres in all settings.

Whenever possible, staff should follow social distancing guidance being at least 2 metres away from the person they support. If this is not possible due to having to provide personal care, or if the person they support has behaviours and needs which make this difficult, then PPE may be needed as highlighted below.

Hand hygiene

Supported living staff should think carefully about ways that the person they support can be encouraged to participate in regular handwashing:

• washing hands with soap and water for at least 20 seconds is essential before and after all contact with the person, removal of protective clothing and cleaning of equipment and the environment
• where possible, promote hand hygiene and ensure that liquid soap and disposable paper towels are available at all sinks in shared areas
• alcohol-based hand rub can be used, where safe to do so, if hands are not visibly dirty or soiled and where appropriate, it should be accessible and have adequate provision
• if people you support are having visitors, encourage them to follow good respiratory and hand hygiene, washing their hands on arrival, during their stay, and on leaving (more details in visitors section)

Respiratory and cough hygiene – ‘Catch it, bin it, kill it’

Disposable single-use tissues should be used to cover the nose and mouth when sneezing, coughing or wiping and blowing the nose. Used tissues should be disposed of promptly. Hands should be cleaned with soap and water, or alcohol hand rub where this is not possible and if safe, after coughing or sneezing, using tissues or after contact with respiratory secretions and/or contaminated objects.

Encourage individuals to keep hands away from the eyes, mouth and nose. Some people may need assistance with containment of respiratory secretions. Those who are immobile will need alcohol hand rub for hand hygiene, and a bag at hand for immediate disposal of the waste potentially contaminated with the COVID-19 virus, such as tissues. These bags should be placed into another bag, tied securely and kept separate from other waste. This should be put aside for at least 72 hours before being put in the usual household waste bin for disposal as normal. Where the person has learning disabilities, it will be important to make sure they understand exactly what they need to do and why.

Visitors and support bubbles

We are currently in a situation where there is sustained community transmission across the UK and a care/support worker should assume that they are likely to encounter people with COVID-19 infection in routine work. Therefore, visits in person should be limited to protect the health and wellbeing of people being supported, their carers and the visitors. In supported living environments the accommodation is the person’s own home, however it may also be a staff workplace.

For some people, there are important reasons for having in-person visits, as not having these may be difficult to understand and lead to distress.

Supported living managers and care/support providers need to work with the people they support to identify where following the government requirements for visiting and support bubbles will cause distress, and consider options for in-person visits.

As of Wednesday 6 January 2021, a new national lockdown is in place across England. Visits with support bubbles are still allowed. Supported living managers, care/support workers, people being supported and their families and friends should follow national guidance on support bubbles and meeting others.

If the person is assessed as not having capacity in relation to this decision, the provider should work within the appropriate MCA framework to establish that a visit is in someone’s best interests.

If the person has capacity and wants a visit, the provider should:

• advise them about the safest ways to have visitors
• risk assess individual settings and individual vulnerabilities consider risks to other people (if in shared settings)
• encourage, agree and support decision-making regarding visitors

It will also be important to consider the risks to visitors themselves and anyone they may later be in contact with, for example an older relative. The above should be achieved by building on relationships to advise people on infection prevention and control:

• no one with COVID-19 symptoms should visit
• no one who should be self-isolating as they have been a close contact of a COVID-19 case in the previous 10 days, or anyone returned from certain countries in the same time period should visit
• if a supported living service has a communal garden area which can be accessed without anyone going through a shared building, then using this space for visits should be encouraged, as long as social distancing measures are met
• alternatives to in-person on-site visiting should be explored, including the use of telephones or video, arranged walks in the park or outdoor spaces. If the person is clinically extremely vulnerable then the currently applicable shielding guidance should be followed
• providers could offer support so people can find/go to outside spaces to see their relative in a safer environment in line with current social distancing rules
• visitors should be encouraged to keep personal interaction with the person they are visiting to a minimum and remain socially distanced for as much of the visit as possible
• numbers of visitors should be limited to the current guidance on group meetings to preserve social distancing as best as possible, and consideration given to staggering visits or other options for limiting simultaneous visits
• if there is not a communal garden area, then visitors should visit the person in the individual’s own room and should be asked to wash their hands for at least 20 seconds on entering and leaving the accommodation. Visitors should take sensible precautions, such as covering the mouth and nose with a tissue when coughing or sneezing (followed by handwashing) or crook of the arm (not the hand) if no tissues are available. Dispose of tissues into a disposable rubbish bag and immediately wash hands with soap and water for at least 20 seconds or use hand sanitiser
• if in shared accommodation, visitors should avoid (or minimise if avoidance is not possible) contact with other people who live there and staff (with face-to-face contact occurring for less than 15 minutes and at least 2 metres apart). Where needed, conversations with staff can be arranged over the phone following an in-person visit
• visitors should be encouraged to wear appropriate face coverings when visiting to protect people in supported living settings
• we note that in some circumstances, visors may be preferable to masks, as a means to facilitate the more effective provision of care and social interaction through non-verbal communication, especially with people with advanced dementia or learning disabilities for whom recognition of familiar staff is critical to reducing agitation and distress. The decision to use visors, would need to be risk assessed for the benefit of the person, and would have to balance with additional risk of transmission
• where possible, visitors can be given support on how to prepare for a visit and given tips on how to communicate if face coverings are required, for example:
  • speaking loudly and clearly
  • keeping eye contact
  • not wearing hats or anything else that might conceal their face further
  • wearing clothing or their hair in a way that the person they are visiting would more likely recognise

If a supported living worker has COVID-19 symptoms

General guidance for working safely during coronavirus is available. If a supported living worker develops COVID-19 symptoms, then NHS advice is available. In addition:

• if symptoms start at home (off-duty), they should not attend work and should notify their line manager immediately
• if symptoms start at work, and the staff member is not wearing a face mask they should immediately put on a surgical face mask, inform their line manager and return home
• if symptoms start at work, and the staff member is wearing a face mask, then this and any other PPE should be removed and disposed of carefully, as described in the domiciliary care resource, hands must be washed, the staff member should immediately put on a surgical face mask, inform their line manager and return home
• staff should get tested as soon as possible and be asked to support all public health requests from NHS Test and Trace and the local health protection teams
• if symptoms do not improve after 7 days, or their condition gets worse, they should speak to their occupational health department if they have one or use the NHS 111 online coronavirus service. If they do not have internet access, they should call NHS 111. For a medical emergency, they should call 999

More details are available from the stay at home guidance and the management of exposed staff and patients in health and social care settings. Staff should not attend work, visit or care for individuals until safe to do so, as described in the staff return to work criteria.

Currently it is not known how long any immunity to COVID-19 might last. If a staff member becomes unwell again, they should self-isolate and may need to be tested again.

Test and Trace

NHS Test and Trace has been established to help identify, contain and minimise the transmission of COVID-19. This will help to reduce the spread of the virus and save lives. The service is designed to:

• provide testing for anyone who has symptoms of COVID-19 to find out if they have the virus
• get in touch with anyone who has tested positive for COVID-19 to help them share information about any close, recent contacts that they have had
• notify those contacts, where necessary, with instructions to stay at home and self-isolate to help stop the spread of the virus

For health and social care worker contacts, NHS Test and Trace will consider whether full medical-grade PPE has been worn in accordance with current guidance on infection prevention and control. This is to assess whether a health or social care worker should be classed as a close contact and asked to self-isolate.

If you are judged by NHS Test and Trace to have had relevant, close contact with someone who has COVID-19, you must stay at home and self-isolate immediately for 14 days and follow the health advice that you will be directed to.

If a supported living worker is concerned they may have been exposed to COVID-19

If a worker or volunteer has come into close contact with a person who is confirmed or suspected of having COVID-19 while not wearing PPE, or had a breach in their PPE, whether within or outside the work setting, then the staff member should inform their line manager, and follow guidance for the management of exposed healthcare workers.

For more information on interpreting test results and the actions required for both symptomatic and asymptomatic individuals, see the flowcharts illustrating the return to work process.

If a supported living worker has symptoms or tests positive (even when asymptomatic)

If a supported living worker is symptomatic, they must stay at home, self-isolate immediately and order a test. Members of their household must self-isolate too. If the test result is negative and the supported living worker does not have COVID-19 and is then well, they can end their period of isolation. If the worker is still ill, though not with COVID-19, for example they have the flu, they should not return to work. Other members of the household do not have to stay at home and isolate if the test result for COVID-19 is negative.

If a supported living worker tests positive for COVID-19, they must self-isolate for 10 days from the date of the test, even if they are asymptomatic. If they remain asymptomatic, they can return to work on day 11. If, during the 10-day isolation, the supported living worker subsequently develops symptoms, they must self-isolate for 10 days from the day the symptoms started.

On testing positive, the supported living worker will be contacted by NHS Test and Trace and directed to a website to input the details of their close, recent contacts. If the worker is unable to use a web-based system, they will receive a phone call from a health professional. As a supported living worker is employed in a health and care setting, the contact tracing process will be escalated to local public health experts, who will liaise with the manager of the relevant setting, if necessary.

The household of the supported living worker should stay at home and self-isolate for 10 days from the day the test was taken. If any member of the household then develops symptoms of COVID-19 during the 10-day period, they should continue to stay at home and isolate for 10 days after the onset of their symptoms, in line with the stay at home guidance. The individual should also arrange a test to check if they have COVID-19.

If a supported living worker is tested while asymptomatic and has a negative result for COVID-19, they can return to work.

If someone in supported living has symptoms of COVID-19

If the person develops a COVID-19 infection, plans need to be developed so that the person is supported to have their health checked in case additional help and health interventions are needed.

It may be harder to recognise COVID-19 infection in people with dementia, autistic people, and people with learning disabilities who may not be able to communicate verbally or easily express the symptoms they are experiencing. This includes signs of a high temperature (37.8°C or above), a cough, or a change in sense of taste or smell, as well as for softer signs, ie being short of breath, being not as alert, having a new onset of confusion, being off food, having reduced fluid intake, diarrhoea or vomiting.

Annex A sets out special considerations when taking swab samples from people who may find the process challenging. It is essential that processes are put in place to enable and ensure the healthcare of these people is effectively supported.

This should include delivery of a rights-based approach such as:

• consideration of all possible diagnostic causes
• access to healthcare
• informing individuals of their rights and ability to challenge decisions
• access advocacy
• use of the hospital passport
• regularly consulting with family members and carers

If a person being supported develops symptoms, then these plans should be acted on to provide additional support and help them self-isolate, and ensure that visitors such as care/support workers and family members follow appropriate procedures such as handwashing, respiratory hygiene and, where appropriate, the use of PPE.

It will be important to be aware of the specific needs of people living with dementia in this regard. For example, people with dementia may not fully understand the significance of, and need for, isolation. They may also find it frightening to see a carer wearing PPE. Simple actions can be taken to mitigate against this such as having the supported care worker’s name and picture clearly visible on clothing, using tone of voice and open body language to demonstrate warmth and drawing or using written words to communicate where appropriate

Plans should include communications to family and others who provide support to help understand the reasons for staying in isolation. The principles underpinning the Mental Capacity Act (2005) should be followed when it is felt a person being supported may lack capacity to make a decision.

Autistic people, people with mental ill health, learning disabilities and dementia may need support in keeping isolated from the people with whom they may share communal facilities. If isolation is not possible within the supported living service, then appropriate alternative community provision may need to be considered. This needs to be discussed with the individual and, where appropriate, family members.

Managing outbreaks in supported living settings

The Health Protection Teams (HPTs) at PHE have an essential role in responding to and supporting any infectious disease outbreaks in supported living settings. Your local HPT will provide tailored infection prevention control advice to ensure staff protect themselves and the people they support.

To confirm the presence of an outbreak, PHE is responsible for the initial risk assessment and initiating testing of suspected outbreaks in supported living settings (depending on local systems in place with other stakeholders such as local authorities and the NHS).

If an outbreak is suspected in a supported living setting, this should be reported to the local HPT immediately. They will undertake an initial risk assessment, provide advice on outbreak management, and decide what testing is needed. Local HPTs will also inform their local partners of the situation.

Find details for your local HPT and more information.

With consent, the person’s GP should be informed if the person who uses services has signs and symptoms compatible with COVID-19.

An outbreak in, or associated with, a supported living setting is defined as within a 14-day period:

1. there are 2 or more confirmed or suspected cases of COVID-19 in a supported living environment
2. a care worker becomes aware that more than one person they support has COVID-19 symptoms, or
3. a care worker and a person who receives care from this worker have COVID-19 symptoms

During an outbreak or when an outbreak is suspected:

• symptomatic people should self-isolate
• if there are any communal areas in the setting which cannot be avoided, then people who are symptomatic or have tested positive for COVID-19 should not attend these communal areas at the same time as others and these areas should be cleaned after use
• if bathrooms or lavatories are not available for sole use by an individual who has tested positive, strict cleaning protocols must be implemented in shared bathroom or lavatory facilities after each use. Where appropriate, any people being supported who are asymptomatic should use separate facilities to those who are symptomatic. The landlord or the care provider should provide a deep cleaning function to all facilities to enable consistent good hygiene practice. For more information on deep cleaning, please refer to the COVID-19 deep cleaning in care homes guidance
• where the supported living environment is cleaned by the tenant, advice and guidance should be offered

Testing

COVID-19 testing for supported living staff and people being supported

All supported living staff displaying COVID-19 symptoms (including symptomatic members of their household) can access a test, as confirmed in the government’s adult social care action plan.

If you are a member of staff and need a COVID-19 test because you are symptomatic, you should self-isolate for at least 10 days from when symptoms started and access testing through the self-referral portal for keyworkers or through receiving a verification code from your employer.

Anyone experiencing coronavirus symptoms can now be tested, which includes people receiving care and support. This can be accessed through the digital portal or via NHS 111 service to book testing.

For people who lack the capacity to consent to testing for themselves, the Mental Capacity Act issues described above apply.

Testing for patients and discharge from hospital into the community

Some people with non-urgent needs, who do not meet the clinical criteria to reside in hospital, will be discharged for their recovery period.

As set out in the COVID-19 adult social care action plan, any individual moving into a supported living setting should be supported as if they were possibly COVID-19-positive until a 10-day period has passed, even where they have tested negative for COVID-19. This should increase to 14 days based on a risk assessment if the setting is considered high risk. Providers will need to follow the relevant guidance for use of PPE for COVID-19-positive people during this period.

All people receiving hospital care will be tested for COVID-19, and hospitals should share care needs and COVID-19 status with relevant community partners planning the subsequent community care. Supported living environments should ensure that support plans are in place to maintain a supportive and planned transfer and are discussed with the person being discharged, and where appropriate their family and care providers.

If the PCR (swab) test has been performed in hospital but the result still awaited, the person may only be discharged if assurance has been gained that appropriate support plans are in place for the requirements of the isolation period to be met.

For autistic people and people with learning disabilities, mental ill health, or dementia it will be particularly important to make sure they and their families understand, before the transfer happens:

• why these arrangements are needed
• what they will look like
• how long they will go on for

It will be important to ask how they feel about this and what, if anything, could make it easier for them.

For people living in shared settings, the views and needs of the people they live with should be taken into account when thinking through the practical arrangements that need to be made at home to reduce the risk of infection, such as that set out in the guidance for households with possible or confirmed coronavirus (COVID-19) infection. This should include their view on the risk to them of sharing their home with the person being discharged whose COVID-19 status is unknown and may include the need to consider if any change in living arrangements is needed, for example to allow the person being discharged to access a separate bathroom and stopping other people visiting the home.

Some living in the home may need support to make sure that advice about what should happen during the isolation period can be followed. This could include not having visitors to the house and cleaning shared areas such as kitchens after use.

If the person being discharged, or anyone they share their home with, lacks capacity to understand information about the discharge arrangements or the requirements of the isolation period, and decisions need to be made that impact on their living arrangements and/or support needs, then the Mental Capacity Act should be followed and people who are significant to them consulted with before decisions are taken in their best interests. Prior to this happening, all steps should be taken to support the person to understand information, which may include using accessible formats such as easy read or having the support of someone who knows them well to communicate information.

Personal protective equipment (PPE)

The risk of transmission should be minimised through safe working procedures, reducing contact and following standard IPC precautions as described in the how to work safely in domiciliary care resource.

The information on PPE below references supported living staff, but also applies to other care providers coming into the environment to provide care. The supported living manager should work with the people who live there and their families to ensure that external care providers follow the guidance. Updated guidance on PPE should be referred to if aerosol generating procedures are being carried out.

Please refer to the correct order of donning (putting PPE on) and doffing (taking PPE off) PPE. For AGPs (aerosol generating procedures) please follow specific PPE guidance. PPE should always be used in accordance with IPC measures and requirements for hand hygiene should include washing of exposed forearms.

Table 1: when providing close personal care in direct contact with the person(s) in a supported living setting (for example, touching) or within 2 metres of anyone in the setting who is coughing

Recommended PPE items	Explanation
Disposable gloves	Single use to protect you from contact with the person’s body fluids and secretions.
Disposable plastic apron	Single use to protect you from contact with the person’s body fluids and secretions.
Fluid-repellent (Type IIR) surgical mask	Fluid-repellent surgical masks (FRSMs) can be used continuously while providing care, unless you need to remove the mask from your face (for example to drink, eat, take a break from duties). You can wear the same mask between different home care visits (or visiting different people living in an extra care scheme), if it is safe to do so whilst travelling. This may be appropriate when travelling between households on foot or by car or by public transport, so long as you do not need to take the mask off, or lower it from your face and providing it does not compromise your safety (for example, driving ability) in any way. You should not touch your face mask. The mask is worn to protect you, the care worker, and can be used while caring for a number of different people regardless of their symptoms. You should remove and dispose of the mask if it becomes damaged, visibly soiled, damp, or uncomfortable to use. If removed, you would then need to use a new mask when you start your next home care visit. Technical Specifications for PPE
Eye protection	Eye protection is recommended for care of people where there is risk of droplets or secretions from the person’s mouth, nose, lungs or from body fluids reaching the eyes (for example, caring for someone who is repeatedly coughing). Use of eye protection should be discussed with your manager and you should have access to eye protection (such as goggles or visors). Eye protection can be used continuously while providing care, unless you need to remove the eye protection from your face (for example, to take a break from duties). We do not recommend continued use of eye protection when driving or cycling. If you are provided with goggles/a visor that is reusable, then you should be given instructions on how to clean and disinfect following the manufacturer’s instructions or local infection control policy and store them between visits. If eye protection is labelled as for single use then it should be disposed of after removal.

The recommendations in Table 2 below apply when within 2 metres of a person but not delivering personal care or needing to touch them, and there is no one within 2 metres who has a cough.

This includes:

• for tasks such as: removing medicines from their packaging, prompting people to take their medicines, preparing food for people who can feed themselves without assistance, or cleaning
• whatever your role in care (ie applies to all staff, care workers, cleaners etc). If practical, household members with respiratory symptoms should remain outside the room or rooms where the care worker is working. They should be encouraged to follow good hand and respiratory hygiene and remain 2 metres away
• if unable to maintain 2-metre distance from anyone in the household who is coughing (including the person receiving care/support) then follow recommendations in Table 1 above

These principles are also suitable for extra care housing schemes. It is important to note that PPE is only effective when combined with:

• hand hygiene (cleaning your hands regularly and appropriately)
• respiratory hygiene and avoiding touching your face with your hands
• following standard infection prevention and control precautions:
  • Healthcare-associated infections: prevention and control in primary and community care (NICE)
  • Standard infection control precautions: national hand hygiene and personal protective equipment policy (NHS England and NHS Improvement)

Table 2: when within 2 metres of a person but not delivering personal care or needing to touch the person(s) in a supported living setting, and there is no one within 2 metres who has a cough

Recommended PPE item	Explanation
Disposable gloves – sometimes required*	* Required if for other reasons set out in standard infection prevention and control precautions (for example, contact with person’s bodily fluids) or if anyone in the household is shielding.
Disposable plastic apron – sometimes required*	* Required if for other reasons set out in standard infection prevention and control precautions (for example contact with person’s bodily fluids) or if anyone in the household is shielding.
Type II surgical mask – required	Type II surgical masks can be used continuously while providing care, unless you need to remove the mask from your face (for example,to drink, eat, take a break from duties). You can wear the same mask between different home care visits (or visiting different people living in an extra care scheme), if it’s safe to do so while travelling. This may be appropriate when travelling between households on foot or by car or by public transport, so long as you do not need to take the mask off, or lower it from your face and providing it does not compromise your safety (for example, driving ability) in any way. You should not touch your face mask. The mask can be used while caring for a number of different people regardless of their symptoms. You should remove and dispose of the mask if it becomes damaged, visibly soiled, damp, or uncomfortable to use. If removed, you would then need to use a new mask when you start your next home care visit. Note: surgical masks do not need to be fluid repellent for use in this situation. However, if you are already wearing a fluid-repellent (Type IIR) surgical mask there is no need to replace it, and if only fluid-repellent (Type IIR) surgical masks are available then these may be used. If the next visit you undertake includes personal care, then you will need to follow recommendations in Table 1 for the next visit. Details on specification can be found
Eye protection	Not required

Cleaning

In supported living environments, cleaning may be carried out by the person who lives there, their family, an external cleaner, or as a service provided as part of the accommodation. Where appropriate the supported living manager should adapt guidance accordingly. Additional guidance is available for cleaning in non-healthcare settings.

If the person you are supporting does their own cleaning or arranges their own cleaner, then staff should consider how the person they are supporting is most likely to understand the information and use the most appropriate communication techniques for that person. With their consent it may be appropriate to place visible guidance such as pictorial posters, or other communication aides to reinforce cleaning messaging.

If the person in the supported living setting has COVID-19 symptoms or has confirmed COVID-19, then their personal waste (for example, used tissues, continence pads and other items soiled with bodily fluids) and disposable cleaning cloths can be discarded in clinical waste bins, where available, or can be stored securely within disposable rubbish bags. These bags should be placed into another bag, tied securely and kept separate from other waste which can be disposed of as per usual practice. This should be put aside for at least 72 hours before being put in the usual household waste bin for disposal as normal. Where the person has a learning disability or other needs, it will be important to make sure they understand exactly what they need to do and why.

Laundry

In supported living environments, laundry may be carried out normally by the person who lives there, their family, an external person, or as a service provided as part of the accommodation. Where appropriate the supported living manager should adapt guidance accordingly. If a laundry service is provided, it should follow the guidance below:

• wash items in accordance with the manufacturer’s instructions. Use the warmest water setting and dry items completely. Dirty laundry that has been in contact with an unwell person can be washed with other people’s items
• do not shake dirty laundry; prior to washing this minimises the possibility of dispersing the virus through the air
• clean and disinfect anything used for transporting laundry with your usual products, in line with the cleaning guidance above

If someone carries out their own laundry duties then with consent it may be appropriate to place visible pictorial reminders, such as posters, or other communication aides in line with the persons individual communication method around the supported living setting, to reinforce the above laundry messaging.

Annex A: taking swabs

This annex sets out special considerations when taking samples from people who may find it difficult to understand what is happening. This could include autistic people and people with learning disabilities, mental ill health, dementia or any other type of cognitive impairment:

• be aware that the person has a cognitive impairment that may impact on their ability to understand information about taking the swab
• find out from those who know them best how and when to give the person information about taking the swab in a way they are most likely to understand it
• having given the information, if it is concluded that the person does not have the mental capacity to understand it and consent to taking the swab, a decision should be made in their best interests following the principles of the Mental Capacity Act 2005. See Coronavirus (COVID-19): looking after people who lack mental capacity
• relevant information about the person’s needs, preferences and understanding should be taken into account, and where possible, a family member or carer who knows them well should be present or at least consulted with to inform the best interests decision
• provide reassurance and use a calm and confident approach
• explain the process step by step using appropriate language and their preferred communication methods. If appropriate, use visual aids to show what is happening
• be prepared to take time when taking the sample and to try more than once if needed, possibly at different times of the day
• if the person becomes distressed at any point, it may be necessary to abandon the attempt to take a sample

Annex B: additional resources

• The Social Care Institute for Excellence has produced guidance for care staff who support autistic people and people with learning disabilities
• The Alzheimer’s Society website has resources to promote awareness of the Herbert Protocol among local emergency services and the local community. The Herbert Protocol is a national scheme that encourages carers, family and friends to provide and put together useful information, which can be used in the event of a vulnerable person going missing
• Examples of factsheets developed by organisations include ‘This is Me’, which contains space for:
  • important routines
  • access to advanced care plans
  • cultural, spiritual, religious and family background
• The Challenging Behaviour Foundation has produced an information sheet about people with severe learning disabilities and face masks. The resource provides useful information about helping people with severe learning disabilities to prepare for the experience of wearing or seeing other people wear PPE.
• Organisations such as Speakup have developed a series of resources such as hospital passports for autistic people or people with a learning disability to help on discharge to hospital, if this was necessary.
• The Housing Learning and Improvement Network have produced various resources related to specialist housing and COVID-19. These include bereavement and emotional support materials.