COVID-19: GUIDANCE FOR NURSING AND RESIDENTIAL CARE HOMES
IN NORTHERN IRELAND
Contents
Introduction ........................................................................................................... 6
For Health and Social Care Trusts ...................................................................... 6
Workforce ........................................................................................................... 6
Personal Protective Equipment (PPE) ............................................................. 8
Financial Support .............................................................................................. 9
Discharge ........................................................................................................... 9
For Care Homes .................................................................................................. 11
Access to PPE .................................................................................................. 11
Maintaining services ....................................................................................... 11
Discharges from a hospital setting ................................................................ 12
Reporting of COVID-19 cases ......................................................................... 14
Support from GPs ............................................................................................ 15
Caring for residents, depending on their COVID-19 status.......................... 15
COVID-19 positive cases ............................................................................. 15
Keeping asymptomatic residents safe and monitoring symptoms ......... 15
Symptomatic residents ................................................................................ 17
Managing an outbreak ..................................................................................... 18
Supporting existing residents who may require hospital care .................... 19
Medicines Management .................................................................................. 20
Oxygen……………………………………………………………………………… 20
Providing care after death .............................................................................. 21
Restrictions on Visitors .................................................................................. 22
End of life visits ............................................................................................... 23
Communication with families and other visitors .......................................... 23
Visits by Health and Social Care Professionals ............................................ 24
When it may be appropriate to move someone to a different home or
facility .............................................................................................................. 24
Infection Prevention and Control (IPC) Measures ........................................ 24
PPE disposal, cleaning and laundry .............................................................. 25
Support and advice ......................................................................................... 26
Regulatory oversight ....................................................................................... 27
For Care Staff ...................................................................................................... 27
Testing for Care Home Staff ........................................................................... 27
PPE – Advice for Staff .................................................................................... 27
Staff who come into contact with a COVID-19 patient .................................. 31
Staff safety ....................................................................................................... 31
Staff training..................................................................................................... 32
Professional Regulation .................................................................................. 32
Support for staff ............................................................................................... 32
Guidance on Deprivation of Liberty (DOL) provisions under the Mental
Capacity Act ..................................................................................................... 33
Staff who experience Covid-19 symptoms .................................................... 33
Annex A – Agreement between HSC and TUS - Transfer of staff to
Independent Sector re COVID-19 ....................................................................... 35
Appendix 1 – PROCESS FOR DEPLOYMENT ................................................ 37
Annex B – Pre-admission infection prevention and control risk assessment
proforma .............................................................................................................. 38
Annex C – Isolation of COVID-19 symptomatic patients ................................. 42
Annex D – Definitions of COVID-19 cases and contacts ................................. 44
Annex E – Contact Points for Independent Sector Staff Testing .................... 45
Annex F – Criteria for shielding vulnerable people in Northern Ireland ........ 47
Annex G – Aerosol Generating Procedures (AGPs) ........................................ 48
Annex H – Information Sharing ......................................................................... 49
Privacy Advisory Committee (PAC) Guidance on the disclosure of COVID-
19 infection status & ICO Position on Sharing Information ......................... 49
April 2020 ......................................................................................................... 49
Information Commissioner’s Position ........................................................... 49
Annex I - Additional sources of training, support and guidance…………… 50
2
Version control
Version Control
Date of issue
Version 1.0
17th March 2020
Version 2.0
26th April 2020
Version 2.1
3rd May 2020
Changes made at Annex E - Contact Points
for Independent Sector Staff Testing
Version 2.2
7th May 2020
Changes made at Annex E – Trust
testing contact points
Version 2.3
29th June 2020
Changes made at Paragraph 32 – to
confirm that patients returned to Care
Homes fol owing attendance at ED
Version 2.4
16th July 2020
Paragraph 32 – clarifying that for
residents who attend hospital for a short
appointment/ assessment for non-COVID
symptoms, and who are not admitted,
are not required to isolate on return to
the home in these circumstances.
Paragraphs 62-63 provide updated
advice on managing an outbreak.
References to Reuse of Patients’ Own
Drugs Protocol removed (paragraph 65 in
previous version) following withdrawal of
this protocol.
Paragraphs 72-86 – updated to reflect
revised visiting guidelines published on 30
June 2020 (guidelines included at Annex J).
Paragraphs 106-117 – PPE advice for
staff updated.
3
Paragraph 125 – amended to clarify that CEC COVID-
19 programmes free of charge for all sectors.
Annex B – updated pre-admission infection
prevention and control risk assessment
proforma.
Annex E – updated contact advised for Western
HSC Trust.
Annexes F and G re-ordered – criteria for shielding
now at Annex F and list of AGPs at Annex G.
Version 2.5
21st July 2020
Annex E – updated hyperlink to Employer Referral
Portal
Version 2.6
11th September 2020
Paragraph 72 – Update to remind readers
to refer to recently issued correspondence
on visiting from the Department.
Version 2.7
10th December 2020
Paragraphs 73 to 83 – Inclusion of
guidance on Christmas visiting to care
homes
Version 2.8
21st December 2020
Paragraphs 25 – 34 setting out revised Discharges from
a hospital setting
Paragraphs 76 - 81 setting out further revisions to the
guidance on Christmas visiting to care homes
Annex B – Revised pre-admission infection prevention
and control risk assessment proforma added.
4
Version 2.9
15th January 2021
Paragraph 75 – Setting out revisions to restrictions to
visitors
Paragraphs 76-79 – Setting out updated revisions to
visiting to Care Homes from 15th January 2021
Version 3.0
2nd April 2021
Insertion of Paragraphs 90-95 – Advice on short Breaks
out of the Care Home Setting
Version 3.1
29th April 2021
Insertion of paragraphs 17 to 20 relating to updated
PHA advice on ability to split self isolation requirement
between 2 facilities.
Updating section on Restrictions on Visitors Paragraphs
81 to 83 to refer to the Pathway Document.
Removal of section relating to Advice on short breaks
out of the Care Home Setting.
Version 3.2
21 June 2021
Updating paragraph 119 – Staff who come into contact
with a Covid 19 patient (following PHA input).
Updating paragraph 134 – Staff who experience Covid 19
symptoms – isolation period updated (following PHA
input).
Updating Annex D (fol owing PHA input).
5
COVID-19: Key messages for providers of residential and nursing care
in Northern Ireland
•
Co-ordination between care providers, the voluntary and community
sector, and the HSC is critical to the success of the strategy for delaying
and treating COVID-19.
•
Workforce: providers and Trusts must plan in partnership, making the
best use of all available assets, to ensure the availability and adequate
training of staff.
•
Discharge: Revised arrangements from hospital settings now in place
based on latest scientific advice
•
Support: The RQIA’s Service Support Team (SST), which was operational
during the crisis, has been stood down. However, Duty Desk Inspectors are
available to support nursing and residential care home providers during this
crisis.
•
Access to PPE: Providers should work with suppliers to secure an
adequate supply of PPE but wil be supported by Trusts where they are
unable to source items.
Introduction
1. This guidance is aimed at Health and Social Care Trusts and registered
providers of accommodation for people who need personal or nursing
care. In addition, there are also important messages for relatives and
friends of those in nursing and residential homes.
For Health and Social Care Trusts
2. Trusts must continue to collaborate with all care home providers
throughout the period of the COVID-19 pandemic. The Health and Social
Care Board has sought approval to free up Trust resources in a number
of areas to enable them to rapidly respond to, focus on and prioritise the
needs and staff requirements associated with the impact of COVID-19.
Workforce
3. Trusts should continue to maintain contact with all registered nursing and
residential homes in their Trust area, and with the RQIA’s Service
Support Team, to discuss and facilitate plans for support. This should
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include ensuring each care home has a named contact in the Trust who
can assist that care home in relation to staffing issues or other business
continuity issues.
4. Trust should have developed robust contingency plans to support nursing and
residential care homes in situations where the home’s individual contingency
plans have been exhausted. This may mean temporarily redeploying Trust staf
to nursing and residential homes to ensure continuity of service. This may
include support service staff such as cooks, catering and nursing assistants, as
wel as professional staff, such as nurses, occupational therapists and
physiotherapists. Care homes should not be charged for Trust employed staff
who move to work in a care home as a result of COVID-19 pressures.
5. Trusts should seek to ensure that multi-disciplinary support, including any
appropriate medical input, is available to homes. Infection control support to
homes is essential and Trusts should focus on ensuring homes that do not
currently have an outbreak have the best possible infection control practices
in place. Trusts wil want to particularly consider the needs of residential
homes, who wil not have nursing support onsite.
6. Trusts should also consider whether domiciliary care workers, including those
from the independent sector, could be deployed to support care homes.
7. Trusts should continue to make best use of all the assets available to the
community. This wil include the voluntary, community and social enterprise
sectors as well as friends, families, carers or other volunteers where it is safe
to do so. Trusts should consider how they can use existing contracts with the
voluntary, community and social enterprise sector to support work related to
COVID-19, including supporting residential and nursing homes.
8. Trusts should prioritise those identified through the HSC workforce appeal,
and who have the right skil s, for deployment with independent social care
providers; or for use as backfil for existing members of staff who can be
deployed. In addition Trusts should work with homes to consider whether any
of the 3,000 volunteers who have registered with Volunteer Now can be
deployed to support social care (but not in posts that are usually paid). Any
deployment of staff or volunteers in this way must be in line with, and
underpinned by, the signed agreement at
Annex A which wil ensure that
appropriate safeguards are in place for both employees and employers.
9. This should include ensuring appropriate induction, clear delegation and
supervision arrangements. Employers have responsibilities to ensure their
staff are trained and supervised properly until they are competent in the
particular environment. Employers should ensure, in particular, that there is an
agreement with care homes that ensures work is appropriately delegated. For
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nurses, this should be in line with guidance from Northern Ireland Practice and
Education Council for Nursing and Midwifery
(http:/ nipec.hscni.net/download/projects/currentwork/provideadviceguidanc
einformation/delegationinnursingandmidwifery/documents/NIPEC-Delegation-
Decision-Framework-Jan-2019.pdf). Most tasks carried out by 6
social care staff wil not require any delegation process and wil be carried out
as part of their core duties and functions as agreed. However if delegation of a
complex task to a care worker by another professional is required then
Circular (OSS) 2/2018,
The Framework for the delegation of complex tasks to
social care workers in Northern Ireland should be followed. Staff wil maintain
their existing terms and conditions. Some common questions and answers on
COVID-19 related staffing issues are available
a
t https:/ www.publichealth.hscni.net/covid-19-coronavirus/guidance-hsc-
staff/questions-and-answers-hsc-staff#what-pay-will-i-receive-if-i-am-absent-
from-work-due-to-covid-19-09-04-2020 which confirms staff wil be paid if they
off work because they are self isolating.
10. Trusts should ensure staff and volunteers are deployed to homes in a way
which minimises the risk of transferring infections between care homes. This
should mean staff only working in one home, as far as is practicable. It may
also mean cohorting staff for care homes with and without infections or
isolating some staff between working in different care homes.
11. Where Trusts have block booked hotels for staff who may need to live away
from their family home, they should work with independent sector providers to
make available any spare capacity for their use. Providers should not be
charged for this.
Personal Protective Equipment (PPE)
12. Trusts must work with nursing and residential homes on the provision of
appropriate PPE, where they are unable to source their own supplies. This
must include ensuring providers are able to hold a buf er of stock, and ensure
provision of PPE is in line with the advice provided on its use in the sections
below. Trusts must work with care homes to understand requirements and
prioritise stock across organisations, where there are any short term limitations
on stock. Trusts should continue to ensure al nursing and residential homes
have a named point of contact with whom to discuss PPE provision. Homes
should not be charged for the provision of PPE from Trust stocks. The HSCB
wil work with Trusts to ensure al Trusts work towards a consistent approach in
the provision of PPE – including how the level of stock to be held by providers
is judged. The Department and the HSC are continuing to pursue al feasible
PPE supply routes in order to ensure al providers wil continue to be able to
access the PPE they need.
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Financial Support
13. Support should also be provided to ensure the financial resilience of care home
providers. Where, as a result of the COVID-19 outbreak a nursing or residential
care home’s income reduces by greater than 20% below the past 3 months’
average then Trusts should block purchase 80% of the vacated beds at the
regional tariff. The Trust should then fil these beds as required over the next
three months, taking account of the factors set out in this guidance and provided
it is clinically safe to do so. If beds are stil vacant at the end of that period a
further review would be undertaken by the Trust working with the HSCB.
Further consideration is being given to financial support for the sector to help
meet the increased costs that providers are facing. These financial measures
are time limited.
Discharge
14. Trusts wil need to work with families and friends to ensure they understand
that those deemed medical y fit and waiting on a residential placement may be
al ocated the first place that is available, where clinically appropriate. This may
not necessarily be the first choice for the individual, their family or friends but it
is important to note that people can subsequently move to the home of their
choice, once it becomes available. The timing of any move wil need to take
into account the need to limit movement between homes to ensure COVID-19
is not spread. Trusts wil arrange any transfers as and when appropriate.
15. Trusts must, however, ensure that all individuals discharged to a care home
have been subject to a COVID-19 test. Where the care home has the resources
to isolate an individual they should accept new or returning residents
discharged from hospital while test results are awaited.
16. Al new residents in care homes should be subject to isolation for 14 days as
per infection control advice. Where care homes are unable to isolate
individuals, Trusts should make arrangements for isolation of such patients in a
suitable setting until they can be admit ed to the care home. The RQIA can offer
advice and support through the Guidance team and/or aligned inspectors when
queries around isolation arise.
17. The isolation advice depends on the COVID-19 status of the patient:
COVID-19 negative
o COVID-19 negative residents should isolate for 14 days within their own
room.
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COVID-19 positive
o If a resident has previously tested positive for COVID-19 and is within 90
days of their initial il ness onset or positive test date, and they have
already completed their 14-day isolation period and have no new COVID-
19 symptoms or exposure, they are not required to have a COVID-19 test
prior to discharge and may not be required to isolate (individual care home
decision).
o If a resident has a new COVID-19 infection the total 14 day isolation
period can be shared across the hospital and care home if infection
prevention and control practices are not breached.
18. Public Health England guidance outlines relevant considerations to facilitate
discharge and share the isolation the 14 day isolation period across the clinical
and care setting – this is fully applicable to care home settings in Northern
Ireland.
19. Updated PHE guidance on the discharge of positive patients/residents from
hospital is available at the following link:
(https:/ www.gov.uk/government/publications/designated-settings-for-people-
discharged-to-a-care-home/discharge-into-care-homes-for-people-who-have-
tested-positive-for-covid-19)
20. The updated PHE guidance explains that:
‘The total 14-day isolation period can be shared across the hospital and
designated setting if infection prevention and control practices are not
breached. If the individual has had a new COVID-19 exposure prior to
discharge, then the 14-day isolation period should start from the day of
the last exposure.’
The PHE guidance also explains that the care home retains the discretion to
isolate a resident if they wish.
21. The PHA IPC Cell has agreed that ‘from an IPC perspective isolation can be
shared across facilities provided all IPC practices and covid secure
behaviours remain in place.’ ‘This means that if an individual has spent 10
days of their 14 day isolation period in hospital, in a COVID-19 secure
environment, with no IPC or PPE breaches or new COVID-19 exposures, they
would only be required to isolate for 4 days on discharge to the care home.’
22. A pre-admission infection prevention and control risk assessment proforma
wil assist nursing and residential care home managers to record relevant
information regarding past or current infection. The risk assessment proforma
is attached at
Annex B for completion by the care home.
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For Care Homes
Access to PPE
23. Where providers are unable to source appropriate Personal Protective
Equipment (PPE) HSC Trusts wil work with care homes to ensure they have
the appropriate equipment available to them. The provision of PPE should
reflect the relevant guidance
https://www.gov.uk/government/publications/wuhan-novel-coronavirus-
infection-prevention-and-control/covid-19-personal-protective-equipment-ppe.
Public Health England (PHE) issued guidance on 17 April 2020 regarding the
reuse of PPE. Advice issued by the Chief Medical and Nursing Officers on the
19th April confirms this guidance has not been implemented in Northern
Ireland at this point in time.
24. Providers must identify any particular issues (such as the requirement for PPE
related to Aerosol Generating Procedures) (AGPs) in good time to Trusts.
25. A single point of contact (SPOC) available both in and out of hours has been
identified in each Trust to be contacted directly by the providers to secure
supplies. Details have been circulated to registered providers separately.
Contact can be made both in and out of hours. Care homes wil not be
charged for any provision of PPE from Trust stocks. This is a time limited
approach, related only to COVID-19.
26. In addition to this support, RQIA has set up a system whereby they wil be
notified daily by the Department of Finance of all offers of external assistance
on PPE which are not deemed of a suitable scale for the HSC’s Business
Services Organisation to engage on. RQIA wil notify all registered providers
of these offers so they have the opportunity to engage directly with suppliers
to purchase products. One hour later this information wil be released to the
wider procurement sector in the public sector.
27. The Department is continuing to monitor the provision of PPE to the
independent care home sector. A very significant volume of PPE has been
and wil continue to be delivered to the independent sector.
Maintaining services
28. Care home providers should continue to implement contingency plans and
continue to work with their usual suppliers, to secure long-term supplies of food,
11
pharmaceuticals, bed linen and other essential supplies. If there are any
disruptions in supply, care homes should work with their local HSC Trust to
consider how any essential support can be provided. Any disruptions should
be flagged immediately.
29. Business continuity plans should be kept under review, with a specific focus
on the workforce. Providers should continue to consider how they can
increase capacity in the event of staff il ness or absence. Providers should
also assess their ability to isolate or cohort residents and be ready to do so.
30. Legislation has been changed so that workers can start after a barred list
check and check of the Northern Ireland Social Care Council (NISCC)
register, provided they are appropriately supervised and the normal pre-
employment vetting information has been requested. Care homes should
encourage new workers to apply for registration with the NISCC and they
must do so within 6 months if stil working.
31. NI Social Care Council (NISCC) registration fees have also been deferred for
new applicants.
Discharges from a hospital setting
32. Al hospitalised care home residents should be discharged as soon as they
are fit, whether they are COVID-19 positive or not. Hospital staff will clarify
with care homes the COVID-19 status of an individual, and any COVID-19
symptoms, during the process of transfer from a hospital to the care home.
See Appendix B
33. Hospital staff should communicate to care home staff about the estimated
date of discharge as soon as possible after admission and diagnosis. This
communication should include the date and result of the first swab and the
planned date of pre-discharge swab.
34. Al hospitalised care home residents who have previously tested negative as
part of hospital routine screening or the investigation of a recent il ness should
be tested for SARS-CoV-2 again 48 hours prior to discharge and the result of
this repeat test relayed to the receiving organisation.
35. If a person is re-tested
within 90 days from their initial il ness onset or test
date and found to stil be positive for SARS-CoV-2, a clinically led approach
should be used to interpret the result and inform subsequent action taking into
account several factors, such as COVID-19 symptoms, underlying clinical
12
conditions, immunosuppressive treatments and conditions, and additional
information such as cycle threshold values. The responsible clinician (e.g. GP
or hospital consultant) should seek clinical advice from an infection control
specialist/microbiologist as required.
36. Immunocompetent residents who have tested positive within the previous 90
days, and remain asymptomatic, should not be re-tested, unless advised by a
clinician if they develop new respiratory symptoms. This is because fragments
of inactive virus can be persistently detected by PCR in respiratory tract
samples following infection, well after a person has completed their isolation
period and is no longer infectious.
37. For asymptomatic people discharged into a care home and who have tested
negative it is recommended that the individual stil isolates for 14 days. Most
homes wil have the facilities to accept these discharges in line with
assessments from the RQIA, Trust or PHA staff.
38. Any resident who tests positive and is being discharged within their 14 days
isolation period should only be discharged to care homes that can provide
effective isolation strategies or cohorting policies, in line with the current
COVID-19 prevention policies.
39. Care homes should treat new residents in the following way:
a) In the very small number of cases where individuals are discharged from
hospital within the 14-day period from the onset of COVID-19 symptoms
they should only be discharged to care homes that can provide effective
isolation strategies or cohorting policies, in line with assessments from
RQIA, Trust or PHA staff
b) For asymptomatic people discharged into a care home and who have
tested negative it is recommended that the individual stil isolates for 14
days. Most homes wil have the facilities to accept these discharges in
line with assessments from the RQIA, Trust or PHA staff.
c) For people who have previously tested positive for COVID-19, they
should continue to appropriately isolate. Most homes wil have the facility
to accept these discharges in line with assessments from the RQIA,
Trust or PHA staff.
d) Most individuals being admit ed to care homes from their own homes wil
have been self-isolating. However, care homes wil want to risk assess
the individual circumstances and agree with the new resident and their
family whether it is appropriate to apply a 14 day isolation policy in each
case.
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40. A cough or a loss of, or change in, normal sense of smell or taste (anosmia)
may persist in some individuals, and is not an indication of ongoing infection
when other symptoms have resolved. . Seek clinical advice as required.
41. Cooperation between healthcare providers, the care home sector and other
care providers–such as community palliative and hospice care is crucial in
managing safe discharges from hospitals and ensure that potential impacts on
patient flow are minimised. These collaborations should also have a long-term
benefit, helping to improve medical care for care home residents by
strengthening relationships between all those who provide them with care.
Reporting of COVID-19 cases
42. Where a single resident has been identified with symptoms of COVID-19, the
requirement for testing should be discussed with the local Trust Care Home
Support Team or equivalent. In the event that a test result is positive Health
Protection Duty Room at the PHA on 0300 555 0119 must be notified.
43. It is important that potential clusters of cases are identified early so that
immediate steps can be taken to prevent spread. If the definition of an
outbreak (i.e. two or more cases within a 14 day period) is met for residents
and/or staff, the person in charge of the care home should first contact the GP
of each affected individual case to arrange clinical assessment. Liaison
between the care home manager, GP, PHA and the Trust needs to be clear to
ensure good communications and consistent practice when clusters emerge.
Primary care services should be accessed as set out in paragraph 37. The
care home management should then notify the Public Health Agency (PHA)
duty room where a clinical risk assessment wil be undertaken by the PHA
duty officer with the care home manager (and if required, GPs). The PHA duty
officer wil advise the care home of what further appropriate action to take.
44. Al staff and residents in a home where there is an outbreak wil now be
tested.
45. Where the PHA has requested that several residents are tested, PHA wil be
notified of the results. The home wil receive notification of results via normal
processes.
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Support from GPs
46. GPs wil continue to provide support to their patients in care homes. In
particular, GPs wil provide each patient with an Advanced Care Plan. GP
practices wil also provide care homes with telephone triage, advice and
support throughout a patient’s il ness.
47. However, unless the practice deems it inappropriate, any call requiring a visit
to the care home wil be passed to the relevant Covid Centre. Care homes
may be asked to submit a standard template of information to support the GPs
clinical decision making.
Caring for residents, depending on their COVID-19 status
COVID-19 positive cases
48. If you are caring for a resident who has been discharged from hospital and
has tested positive for COVID-19, the discharging hospital wil provide you
with the following information upon discharge: -
•
The date and results of any COVID-19 test;
•
The date of the onset of symptoms; and
•
A care plan for discharge from isolation.
49.
Annex C provides further information on the appropriate isolation required for
care home residents who have been discharged from hospital following
treatment for COVID-19.
Keeping asymptomatic residents safe and monitoring symptoms
50. Care home providers should follow social distancing measures
(https://www.gov.uk/government/publications/covid-19-guidance-on-social-
distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-
everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults) for
everyone in the care home, wherever possible, and the shielding
(https://www.gov.uk/government/publications/guidance-on-shielding-and-
protecting-extremely-vulnerable-persons-from-covid-19) guidance for those in
the extremely vulnerable group.
51. Enhanced measures should be put in place to seek to protect residents. This
should include additional cleaning, restricting residents to their rooms as far as
15
possible and strictly limiting any use of communal areas (in line with social
distancing guidance). Homes may wish to encourage residents to take meals
in their rooms (provided this can be overseen safely) and should manage any
use of communal dining rooms to ensure social distancing is maintained.
Homes may wish to encourage staff to change their clothes on arrival to
homes and to ensure they continue to wash their uniforms before each shift in
line with the infection control manual
(https:/ www.niinfectioncontrolmanual.net/).
52. As far as possible homes should seek to limit turnover in staff they use and
seek to limit the number of staff moving between different homes. This might
include block booking agency staff to ensure consistency. We recognise that
there may be a tension between ensuring homes are appropriately staffed and
minimising the number of different staff members working in the home.
53. As far as possible staff should work in groups who are limited to particular
groups of patients and/or parts of the care home.
54. We are also strongly supportive of care home workers sleeping in homes,
providing that can be done safely and with due regard to the need to ensure
social distancing between staff when not working and with the agreement of
workers. We are considering how we can provide support to these initiatives.
55. As part of their employer’s duty of care, providers have a role to play in
ensuring that staff understand and are adequately trained in safe systems of
working, including donning and doffing of personal protective equipment.
56.
All care homes should be monitoring unaffected residents and staff
twice daily. Staff working while symptomatic is a key risk for the spread of
infection in a home. Monitoring should involve temperature taking, asking
about and looking out for the following symptoms:
•
a fever (≥37.8°C)
•
a new persistent cough, or worsening of an existing cough
•
new or worsening shortness of breath
However, staff should be aware that symptoms may be atypical in care
home residents (see paragraph 56).
57. Staff and residents should made aware of what to do if someone develops any
of the above symptoms. Homes may wish to display the poster available at
https://www.publichealth.hscni.net/publications/guidance-management-covid-
19-care-homes-and-other-residential-facilities
16
58. Monitoring is particularly important for residents with dementia and cognitive
impairment who may be less able to report symptoms because of
communication difficulties. Staff should be alert to the presence of other signs
that the resident is unwell as well as symptoms of the virus. This could include
delirium and changes in behaviour, which people with dementia are more
prone to suffer from if they develop an infection.
59. For people with a learning disability, autism or both we suggest that you read
this guidance
https:/ www.england.nhs.uk/coronavirus/wp-
content/uploads/sites/52/2020/03/C0031Specialty-guideLD-and-
coronavirus-v1-24-March.pdf which has good information about the
additional things to do if you are caring for this group of people.
60. For residents with dementia, a learning disability or mental health issues there
may be challenges maintaining the protective measures. Implementing
measures including isolation and social distancing may have adverse effects
that need to be considered.
61. These factors may be more marked for these residents who may be at
increased risk of becoming anxious, frustrated and distressed by isolation or
social distancing measures. Therefore consistency in familiar and daily
routines should be maintained as much as possible. The appropriate use of
language and suitable methods of communication, such as easy read or
pictorial literature, or communication passports, wil need to be considered.
62. The use of PPE may also increase anxiety and distress in a resident with
dementia, learning disability or with mental il health, or evoke an unexpected
reaction. Staff should implement proactive measures that explain their
appearance in ways that the person understands, in trying to minimise any
negative reaction.
63. It may also be more difficult to implement and monitor measures like isolation,
social distancing, frequent hand hygiene and good respiratory hygiene.
Consideration should be given to cohorting where possible, regular assistance
with hand washing and provision of individualised activity.
64. Where it has proved difficult or detrimental to help residents stay in their own
room, social distancing measures must be implemented in any shared spaces.
Alternative ways to meet specific and sensory needs should be explored.
Restraint should not be used to manage social distancing.
Symptomatic residents
65. Symptoms may be atypical or more nuanced in older people with co-
morbidities in care homes who may present with Influenza Like Il ness (ILI),
17
respiratory il ness, new onset confusion, reduced alertness, reduced mobility,
increased falls, delirium, or diarrhoea and sometimes do not develop fever. A
dry cough may develop late. Such changes should alert staff to the possibility
of a new COVID-19 infection. Homes therefore need to be extremely vigilant
to changes in residents and be particularly alert to any unexplained deaths.
Definitions of COVID-19 cases and contacts are at
Annex D.
66. Any resident presenting with symptoms of COVID-19 should promptly be
isolated. This should be in in a single room with an ensuite bathroom, where
possible. Staff should immediately instigate ful infection control measures to
care for the resident with symptoms, which wil avoid the virus spreading to
other residents in the care home and stop staff members becoming infected.
67. Advice is available on the PHA website
(https://www.publichealth.hscni.net/) or
from the RQIA
(https://www.rqia.org.uk/) or through the Service Support Team
(SST). NHS 111 can be contacted for advice. If further clinical assessment is
required, the resident’s GP should be contacted.
68. Homes should continue to monitor the resident and if symptoms worsen
during isolation or are no better after 7 days, contact the resident’s GP for
further advice around escalation and to ensure person-centred decision
making is followed.
69. For residents with dementia, learning disability or mental il health there may be
challenges in maintaining a period of isolation.
Support with regular
handwashing and good respiratory hygiene wil be essential. Anticipating
needs such as hunger, thirst, pain, or wishing to use the toilet, alongside
provision of purposeful activity and appropriate levels of supervision for both
the individual and throughout the care home may help to facilitate isolation.
Virtual methods for contacting family and friends should be explored.
Consideration may have to be given to use of fluid resistant surgical masks for
a resident who cannot tolerate isolation and who wil agree to wear a mask.
Restraint should not be used to manage isolation.
70. Useful guidance developed by the Northern Trust on COVID-19 and dementia
wil be issued separately.
Managing an outbreak
71. COVID-19 should be suspected in any resident with a persistent cough (with
or without sputum), nasal discharge or congestion, hoarseness, sore throat,
wheezing, sneezing, loss of sense of smell or taste, or high temperature (at
least 37.8°C). However, COVID-19 in care home residents can present with
non-respiratory symptoms. These include loss of appetite, new
onset/worsening confusion, or diarrhoea. Care home staff, with detailed
18
knowledge of residents, is well-placed to intuitively recognise these subtle
signs (‘soft signs’) of deterioration. We encourage care home managers/senior
staff to discuss any atypical symptoms of concern with the dutyroom for
advice and risk assessment.
72. It is important to identify both single cases and potential clusters of cases.
Early identification allows immediate steps to be taken to prevent spread. If
you have single cases or potential clusters of cases in residents and/or staff,
the person in charge of the facility should:
•
contact the GP of each affected individual case to arrange clinical
assessment.
•
For a medical emergency dial 999 and advise the call handler of
the presence of COVID-19 symptoms.
•
In the event of a suspected outbreak (defined as 2 or more people
meeting the case definition for a possible or probable case of COVID-
19, within the same 14 day period amongst staff or residents), the
Health Protection Duty Room, PHA must be notified on 0300 555
0119. This line is open Monday-Friday 9am-5pm. The PHA will
provide expert advice and support.
Supporting existing residents who may require hospital care
73. If you think one of your residents may need to be transferred to hospital for
urgent and essential treatment, consider the following checklist:
(a) If a resident shows signs of deterioration
Assess the appropriateness of hospitalisation: consult the resident's Advance
Care Plan/Treatment Escalation Plan and discuss with the resident and/or
their family member(s) as appropriate following usual practice to determine if
hospitalisation is the best course of action for the resident. Consider whether
support from services such as Acute Care at Home teams is appropriate.
(b) If hospitalisation is required and the resident has suspected or confirmed
Covid-19:
•
Follow Infection Prevention and Control guidelines for patient
transport; and
•
Inform the receiving healthcare facility that the incoming patient
has COVID-19 symptoms.
(c) If hospitalisation is not required and the resident has suspected or confirmed
Covid-19:-
19
•
Follow infection prevention and control, and isolation procedures
and consult the resident’s GP for advice on clinical management /
end of life care as appropriate.
(d) If a resident requires support with general health needs:-
•
Consult the resident's Advance Care Plan;
•
Consult the resident's GP and community healthcare staff to seek
advice.
(e) Postpone routine non-essential medical and other appointments:-
•
Review and postpone all non-essential appointments (medical
and non-medical) that would involve residents visiting the hospital
or other health care facilities; and
•
If medical advice is needed to manage routine care, consider
arranging this remotely via a phone call with the GP or named
clinician.
Medicines Management
74. Existing arrangements should be used for the supply and delivery of
medicines to care homes from community pharmacies. Good relationships
between homes and pharmacies have been developed over many years and
should be utilised and built upon at this time.
75. It is recognised that there wil be particular medicines related challenges for
patients with COVID-19 infection which may require medicines to be stopped
or changed. Work wil be undertaken to mobilise the skil s of clinical
pharmacists in Trusts and general practice to support staff and prescribers
requiring medicines advice for critically il patients.
Oxygen
76. It is recognised that the demand for oxygen wil be increased as COVID cases
emerge within care settings. Work is being undertaken to enhance home
oxygen services provided by BOC and community pharmacy in order to meet
this need and ensure there is a reporting system to highlight risks of supply
issues
http://www.hscbusiness.hscni.net/pdf/letter%20oxygen%20NH%20covid%20p
atients%2010%20April.pdf
20
Providing care after death
77. The infection prevention and control (IPC) precautions described in this
document continue to apply whilst an individual who has died remains in the
care home. This is due to the ongoing risk of infectious transmission via
contact, although the risk is usually lower than for those living.
78. Public Health England’s (PHE’s) Rare and Imported Pathogens Laboratory
has assessed the post-mortem risk from people who have died of coronavirus
(SARS-CoV2) infection and has identified little residual hazard apart from:
•
potential droplet generation from artificial air movement during the
initial care of the deceased; and
•
post-mortem examination where the use of power tools take place,
which is a risk for aerosol generation.
79. Guidance surrounding deaths and COVID-19 is available here
ht ps://www.health-ni.gov.uk/publications/covid-19-guidance-surrounding-
death. Registered Nurses who have completed relevant training wil stil be
able to verify life extinct (VLE) in the appropriate circumstances. (DoH (2020)
Guidelines for Verifying Life Extinct (VLE) during COVID-19 pandemic).
80. The Public Health Agency advises the following actions upon the death of a
care home resident with suspected or confirmed Covid-19:-
a. Once the person has died, all visits to the deceased person must
stop. This includes visits from close family and friends.
b. The deceased person must:-
> remain in isolation in their own room if this is already in place.
> if not already isolated, this should be put in place
immediately:-
•
advise others not to enter the room.
•
place signage on the door restricting entrance.
> if death occurs outside of the deceased’s own room:
•
all other residents in the vicinity should be moved to
another room;
•
they must maintain a distance of 2 metres from the
deceased whilst in the same room and whilst being
moved to another room; and
•
They must continue to socially distance from each other
in the room they are relocated to.
21
c. Care home staff must:
•
not enter the deceased’s room unless they are wearing
appropriate PPE in line with standard infection control
precautions. This includes disposable gloves, plastic
apron, fluid resistant surgical mask and eye protection
(if there is a risk of splashing);
•
if not already done, place surgical mask over face and
nose of the deceased;
•
limit time in the isolation room and limit exposure to the
environment in the isolation room;
•
restrict access to the minimum essential staff only; and
•
put a “do not enter” sign on the door.
d. Funeral Arrangements:-
•
ensure that funeral directors are notified of the suspected
or confirmed infectious condition including COVID-19;
•
ensure funeral directors are wearing appropriate PPE
when moving the deceased; and
•
ensure a safe route for transfer of the deceased person
from the premises to the funeral directors’ vehicle. This
should ensure that other residents and staff remain
socially distanced.
e. Terminal Cleaning:-
•
It is estimated that viable virus could be present for up to
48 to 72 hours on environmental surfaces in “room air”
conditions. Once the room is vacated, terminal cleaning
as per PHA guidelines is required. Appropriate PPE
should be worn.
Restrictions on Visitors
81. Al nursing and residential care homes should follow the guidance set out in
‘COVID-19: REGIONAL PRINCIPLES FOR VISITING: NURSING &
RESIDENTIAL CARE HOMES IN NORTHERN IRELAND - Visiting with
Care - A Pathway’ which was published on 30 April 2021, and takes effect
from 7 May 2021. The revised guidance can be found at:
ht ps://www.health-ni.gov.uk/sites/default/files/publications/health/doh-
visiting-with-care-a-pathway.pdf 22
82. It should be noted that if a resident leaves the premises under the terms of the
Pathway for a short period of time only (i.e. not overnight) and follows the
advice on Infection Prevention and Control, there would be no need to
undertake the 14 days isolation that may have been required previously.
83. As the situation remains fluid, this guidance wil be kept under review, and the
approach to visiting arrangements within care homes may be further amended
as new evidence emerges.
End of life visits
84. A resident may have indicated in their Advance Care Plan who they would like
to visit as they approach end of life. If this has not been recorded, a resident
approaching end of life should be asked where possible who they would like to
visit. Family, next of kin and/or appropriate others may be able to advise where
a resident is unable to provide this information themselves. Al requirements in
terms of the care home’s visiting policy, which includes IPC measures, use of
PPE etc. must be adhered to.
Communication with families and other visitors
85. Care homes should ensure good communication with families and friends on
these restrictions and ensure ongoing communication to assure families and
friends about the ongoing quality of care and wellbeing of residents. Care
homes should communicate the detail of their visiting policies to residents,
family and other visitors.
86. Friends and family should be advised that their ability to visit care homes is
stil being controlled in accordance with regional guidance and the care
home’s risk assessment, and is subject to the specific circumstances of the
care home and those living and working within it.
87. Where care homes are proposing to take a bespoke approach to a specific
resident, it should seek to engage family and other likely visitors, as well as
the resident where appropriate, in this decision.
88. We recognise that where homes have reduced staffing levels because of
il ness or self-isolation, families may find that opportunities to speak to staff or
their relatives are more limited than they would wish. Trusts should consider
how they can support homes with communication to families, just as they
should be considering support in delivering care to residents.
89. As set out in paragraph 56 presentation of COVID-19 in care home residents
may be atypical. Close communication with families may help to identify
changes in behaviour, which could be an early indication of infection and allow
23
care homes to better support the individual and guard against any spread of
infection within the home.
Visits by Health and Social Care Professionals
90. Providers must ensure relevant Health and Social Care professionals continue
to have access to residents where they need to in order to carry out any
essential assessments or deliver care. In order to maintain a reduced footfall
through Care Homes, virtual appointments should continue where the relevant
HSC professional deems it appropriate and is able to facilitate. This wil not be
the case in all circumstances. Visiting professionals must adhere to al of the
Care Home’s IPC requirements, where it is necessary that they undertake a
face to face appointment with a resident. Care Homes should not allow
through-premises deliveries.
When it may be appropriate to move someone to a different home or facility
91. Advice on cohorting and isolation is included at
Annex C. Cohorting and
isolation within a nursing or residential home in order to limit spread of
infection may in itself present unintended consequences, such as changes in
behaviour, distress from being in an unfamiliar environment or increased
levels of anxiety. This wil also be the case if the option to move a resident out
of their usual care home to another facility is available and is being
considered.
92. In extreme circumstances such moves can contribute to a rapid and critical
deterioration in a resident’s physical and mental health. Ideally care homes
should aim to maintain as many usual routines as is possible. Where
cohorting, isolation or relocation are under consideration, a discussion
between the resident, and/or their relative/representative, the care home, the
Trust and any other relevant persons should include holistic consideration of
the benefits and risks of the proposed protective measure.
93. Interventions and measures that aim to limit unintended consequences should
be agreed. Al parties involved wil need to understand that in most
circumstances, these decisions wil need to be taken quickly. It may therefore
be helpful to undertake and record discussions that consider all available
options in advance of such a situation arising.
Infection Prevention and Control (IPC) Measures
94. Care homes are not expected to have dedicated isolation facilities for people
living in the home. However, they should implement isolation precautions
when someone in the home displays symptoms of COVID-19 in the same way
24
that they would operate if an individual had influenza or diarrhoea and
vomiting, implementing the following precautions: -
•
If isolation is needed, a resident’s own room can be used. Ideally
the room should be a single bedroom with en-suite facilities.
Where this is not available, a dedicated bathroom near to the
person’s bedroom should be identified for their use only.
•
Protective Personal Equipment (PPE) should be used in line with
current guidance which can be accessed.
•
Room door(s) should be kept closed where possible and safe to
do so. Where this is not possible ensure the bed is moved to the
furthest safe point in the room to try and achieve a 2 metres
distance to the open door as part of a risk assessment.
•
Al necessary procedures and care should be carried out within
the resident’s room. Only essential staff (wearing PPE) should
enter the resident’s room.
•
Entry and exit from the room should be minimised during care,
specifically when these care procedures produce aerosols or
respiratory droplets (AGPs).
•
Ensure adequate appropriate supplies of PPE and cleaning
materials are available for all staff in the care home.
•
Al staff, including domestic cleaners, must be trained and
understand how to use PPE appropriate to their role to limit the
spread of COVID-19.
•
Dedicate specific medical equipment (e.g. thermometers, blood
pressure cuff, pulse oximeter, etc.) for the use of care home staff
for residents with possible or confirmed COVID-19. These should
be single use devices only, provided they are available. It is no
longer appropriate to share such equipment.
•
Restrict sharing of personal devices (mobility devices, books,
electronic gadgets) with other residents.
PPE disposal, cleaning and laundry
95. It is essential that used PPE is stored securely within disposable rubbish bags.
These bags should be placed into another bag, tied securely and kept
separate from other waste within the room. This should be put aside for at
least 72 hours before being disposed of as normal. Homes should have well-
established processes for waste management. See
https://www.niinfectioncontrolmanual.net/cleaning-disinfection
96. Nursing and residential homes should clean frequently touched surfaces.
Personal waste (such as used tissues, continence pads and other items soiled
25
with bodily fluids) and disposable cleaning cloths can be stored securely within
disposable rubbish bags. These bags should be placed into another bag, tied
securely and disposed of as clinical waste. For those care homes that do not
have clinical waste facilities, used PPE should be double waste bagged, tied
securely and stored in the waste disposal area for 72 hours before placing in
the waste disposal bin.
97. Dirty laundry should not be shaken. This wil minimise the possibility of
dispersing virus through the air. Items should be washed as appropriate in
accordance with the manufacturer’s instructions. Dirty laundry that has been in
contact with an il person can be washed with other people’s items. Items
heavily soiled with body fluids, such as vomit or diarrhoea, or items that cannot
be washed, should be disposed of, with the owner’s consent. If a resident has
symptoms of COVID-19, staff should advise families who normally take their
relative’s laundry home to wash that the laundry must be washed by staff on-
site.
Support and advice
98. Queries and contacts related to individual case management should continue
to be directed to HSC Trusts.
99. RQIA has set up a Service Support Team. The work of this team wil include
provision and coordination of support to independent sector providers of
nursing and residential care homes. This wil involve (a) provision of guidance,
advice and resolution, collation and coordination of information from Trusts for
providers; and (b) collation of information for Trusts and Department from the
sector to support clarity.
100. Care homes should contact a central RQIA number 02895361111 or RQIA
Update Ap
p https://rqiani.glideapp.io for all matters related to operational
management of services. The SST service is available 7 days a week from
8.00am to 6.00pm and is supported by a range of inspectors with knowledge
and expertise of the sector.
101. The Public Health Agency co-ordinates a dedicated team of infection and
prevention control nurses, who wil provide advice and guidance in the event
of an outbreak.
102. In addition, the PHA wil continue to re-direct resources previously focused
on working to support care home transformation, to support homes in how
they manage COVID-19 outbreaks and minimise the likelihood of infection.
26
Regulatory oversight
103. RQIA will work with providers to support them to make risk-assessed and
evidence-based decisions using their professional judgement and knowledge
and understanding of the people they provide services to. This wil include
RQIA working with providers to come to solutions to issues that may be outwith
the let er of standards or regulations but which provide safe, pragmatic
remedies to issues that could never have been planned for on this scale.
104. NISCC have made clear that their fitness to practice process wil focus on
high risk concerns.
For Care Staff
Testing for Care Home Staff
105. Al symptomatic care home staff or care home staff who are self-isolating
because a member of their household is symptomatic have access to testing.
Annex E provides details of contact points to arrange these tests.
106. The significance of the results of any test wil need to be considered. Al
care homes should have access to a Single Point of Contact in their local
Trust for return to work advice. Updates to the testing protocol wil be provided
as necessary to care homes, through the RQIA.
PPE – Advice for Staff
107. The use of PPE in Northern Ireland reflects UK-wide guidance, which is
updated in line with new evidence. Staff working in care homes are advised to
refer to the online guidance regarding PPE. Referring to the online guidance
wil ensure staff have access to the most up-to-date information. The most
recent
guidance
is
available
at
https://www.gov.uk/government/collections/coronavirus-covid-19-personal-
protective-equipment-ppe.
Note: PPE is only effective when combined with:
> hand hygiene (cleaning your hands regularly and appropriately);
> respiratory hygiene
> avoiding touching your face with your hands, and
> following standard infection prevention and control precautions
https://www.niinfectioncontrolmanual.net/
108. Public Health England (PHE) issued guidance on 17 April 2020 regarding the
reuse of PPE. Advice issued by the Chief Medical and Nursing Of icers on the
27
19th April, confirms this guidance has not been implemented in Northern Ireland
at this point in time however proportionate and appropriate use of PPE is
encouraged at all times based on risk assessment.
109. For direct patient/ resident care e.g. personal care, toileting and physical
assistance (or within 2 metres of a patient/ resident who is coughing) with
possible or confirmed cases of COVID-19 staff should use:
•
Disposable gloves (single use)
•
Disposable plastic apron (single use)
•
Fluid-resistant (Type 11R) surgical mask (sessional use)
•
Eye/face protection (sessional use if deemed required after a
risk assessment because of e.g. the risk of contamination with
splashes, droplets or blood or body fluids)
When performing a task requiring you to be within 2 metres of a resident but
no direct contact with the patient/resident (i.e no touching) with possible or
confirmed cases of Covid-19, e.g. meal rounds, medication rounds,
prompting people to take their medicines, staff should use:
- Fluid-resistant (Type 11R) surgical mask (sessional use)
- Eye/Face protection (sessional use if deemed required after a risk
assessment because of for example the risk of contamination with
splashes, droplets or blood or body fluids).
- Disposable colour coded aprons in line with standard IPC precautions
and/or food hygiene principles
Working in a communal area with possible or confirmed cases Covid-19 and
unable to maintain 2 metres social distance staff should use a
- Fluid resistant (Type 11R) surgical mask (sessional use)
110. For direct care to any individual meeting criteria for ‘shielding’ (that is, those
who are in a vulnerable group) in any setting, as a minimum, single use
disposable plastic aprons and gloves, sessional use fluid resistant surgical
mask must be worn for the protection of the patient. The criteria for an
individual to be classed in a vulnerable group and subject to shielding in
Northern Ireland are set out at
Annex F. Al individuals in this group should
have received a letter from their GP stating that is the case.
111. If an individual is not in one of the vulnerable groups defined at
Annex F
they may stil be in a group at increased risk of severe il ness from
coronavirus. This should be taken into account when making any risk
assessments. Those at increased risk are defined in social distancing
guidance:
https://www.gov.uk/government/publications/covid-19-guidance-
onsocial-distancing-and-for-vulnerable-people/guidance-on-social-distancing-
foreveryone-in-the-uk-and-protecting-older-people-and-vulnerable-adults.
28
112. A single session refers to a period of time where a health and social care
worker is undertaking duties in a specific clinical care setting or exposure
environment. In this guidance document, we refer to wearing masks and eye
protection continuously until you take a break. The period of duty between
your breaks is the equivalent to what we refer to as a “session” in the main
PPE guidance.
29
113. Where you need to remove your mask (e.g. to take a drink or eat) then you
need to replace it. Do not dangle your mask or eye protection around your
neck or otherwise, and do not place it on a surface for later re-use.
114. When performing an Aerosol Generating Procedure (AGP) on an individual
with a possible or confirmed case staff should use:
• Disposable gloves (single use)
• Disposable fluid repellent coverall gown (single use)
• Filtering face piece respirator (single use)
• Eye/face protection (single use)
115. HSC Trusts wil act as a point of contact for all nursing and residential care
homes to arrange to “fit test” of FFP3 masks for AGP equipment for staff,
ensuring that each individual member of staff uses the appropriate size of
protective equipment to ensure maximum protection from infection.
Thereafter, where a filtering face piece respirator is necessary, it should be fit
checked every time it is used. A list of AGPs is at
Annex G.
116. A visual guide to PPE for both AGP and non-AGP patients can be found at:
https://assets.publishing.service.gov.uk/government/uploads/system/uploads/
at achmentdata/file/878056/PHECOVID-19visualguideposterPPE.pdf. The
PHA poster and factsheet provides guidance on protecting your skin from
damage which can be caused by wearing a respirator mask
ht ps://www.publichealth.hscni.net/publications/keep-calm-and-protect-your-
skin-poster-and-factsheet
30
117. In clinical areas, communal waiting areas and during transportation, it is
recommended that residents with possible or confirmed COVID-19 cases
wear a fluid resistant surgical face mask if this can be tolerated. The aim of
this is to minimise the dispersal of respiratory secretions, reduce both direct
transmission risk and environmental contamination.
118. A face mask should
not be worn by patients if there is potential for their
clinical care to be compromised (for example, when receiving oxygen therapy
via a mask). A face mask can be worn until damp or uncomfortable.
Staff who come into contact with a COVID-19 patient
119. Staff who come into contact with a COVID-19 patient while not wearing the
appropriate PPE wil be considered a close contact and must self-isolate for
10 full days and book a PCR test. Staff who come into contact with a COVID-
19 patient while wearing the appropriate PPE may not be required to self-
isolate based on a risk assessment completed by the PHA Duty Room.
Staff safety
120. A risk assessment is required for health and social care staff at high risk of
complications from COVID-19, including pregnant staff. Employers should:
•
refer to the Government guidance on social distancing for vulnerable
people at
ht ps:/ www.gov.uk/government/publications/covid-19-
guidanceon-social-distancing-and-for-vulnerable-people
•
ensure that advice is available to all staff, including specific advice to
those at risk from complications.
121. Bank and agency staff should follow the same deployment advice as
permanent staff.
122. In the event of a breach in infection control procedures, staff should be
reviewed by their occupational health service where they have one.
31
123. As part of their employer’s duty of care, providers have a role to play in
ensuring that staff understand and are adequately trained in safe systems of
working, including donning and doffing of personal protective equipment.
Staff training
124. Al care home staff, including volunteers and temporary staff, should
receive or refresh training and/or guidance on: a) infection prevention and
control, and b) the use of PPE equipment.
125. The Northern Ireland Social Care Council has published a free resource on
its learning zone on infection control, hand hygiene and using PPE -
https://learningzone.niscc.info/learning-resources/96/supporting-good-
infection-control.
126. The HSC Clinical Education Centre (CEC) provides training, including on-
line infection prevention and control programmes (these are available at
www.hsclearning.com). In addition there are new programmes from the CEC
aimed at those staff who do not regularly look after respiratory patients and/or
have limited ward/community based experience alongside a number of clinical
skil s type programmes to support staff dealing with respiratory patients. CEC
programmes related specifically to COVID-19 are open free of charge to all
sectors across Northern Ireland.
127. Care home providers should ensure that all domestic and catering staff
have received up-to-date training and/or guidance on infection control in the
context of food preparation and service and cleaning.
Professional Regulation
128. The Nursing & Midwifery Council (NMC) has provided guidance for nursing
staff regarding their regulatory role during the Covid-19 emergency period. In
addition, Northern Ireland Social Care Council (NISCC) has confirmed that
their fitness to practice process wil focus on high risk concerns.
Support for staff
129. Trusts should continue to open up their internal resources to care home
staff. Psychological Support Helplines which are staffed by psychologists and
psychological therapists are available to staff in the independent sector. They
are available to provide appropriate support throughout the surge phase of the
crisis. Helpline numbers and other resources are available on the PHA
32
website:
https://www.publichealth.hscni.net/covid-19-
coronavirus/guidance-hsc-staff/staff-health-and-wellbeing
130. Free travel is available to those working as art of the health and social care
system. A letter providing further details has recently been reissued to all care
home providers.
Guidance on Deprivation of Liberty (DOL) provisions under the Mental Capacity
Act
131. Where any admission to a care home amounts to deprivation of liberty, the
Mental Capacity Act 2016 – Deprivation of liberty Safeguards must be adhered
to. Any deprivation of liberty under the Mental Capacity Act / Deprivation of
Liberty Safeguards must be authorised. The Act contains emergency
provisions providing protection from liability even if al additional safeguards are
not met. If a person takes al reasonable steps to put the additional safeguards
in place the person is protected from liability. That means in some
circumstances a deprivation of liberty can be treated as authorised, even if not
authorised by a Trust panel.
132. However, the situation is only an emergency if all reasonable steps have
been taken to put the safeguards in place. In all cases the person doing the
deprivation of liberty must have reasonable belief that the person lacks
capacity, that the deprivation of liberty is in the best interests and that the
prevention of serious harm condition is met. Also, the use of the emergency
provision must be considered on a case by case basis and cannot be used as
a blanket measure not to put certain additional safeguards in place, such as
authorisations.
133. Temporary measures are in place for the detentions under the Mental
Capacity Act. Temporary Codes of Practice have, together with temporary
forms, been published on the Department of Health’s website
www.health-
ni.gov.uk/mca
Staff who experience Covid-19 symptoms
134. Advice
is
available
on
the PHA website
(https:/ www.publichealth.hscni.net/news/covid-19-what-situation-northern-
ireland#preventing-the-spread-of-infection) for staff who believe they have
Covid-19 symptoms or who have a household member who experience
symptoms. Staff who have COVID-19 symptoms should:
•
Not attend work if they develop relevant symptoms, even if they are
mild.
33
•
Notify their line manager immediately.
•
Seek appropriate testing (as below).
•
If necessary, self-isolate for 10 days and fol ow the guidance for
household
isolation
(https:/ www.gov.uk/government/publications/covid-19-stay-at-home-
guidance/stay-at-home-guidance-for-households-with-possible-
coronavirus-covid-19-infection#laundry).
135. Care workers in critical frontline roles can access COVID-19 tests. However,
using a negative result to allow someone to return to work is not completely
without risk and wil need to be carefully considered in line with advice from the
Trust. The RQIA SST wil also be able to provide advice if needed.
34
Annex A – Agreement between HSC and TUS - Transfer of staff
to Independent Sector re COVID-19
TERMS OF AGREEMENT BETWEEN THE HSC AND AGENDA FOR CHANGE
TRADE UNIONS REGARDING PROVISION OF PUBLIC-EMPLOYED STAFF
TO SUPPORT THE INDEPENDENT CARE SECTOR IN THE CONTEXT OF
COVID-19
This is a regional agreement and covers all HSC employers. There wil be
no variation from this document
1. The requirement for HSC staff to be deployed to the independent care sector
wil be based on an assessment by any independent sector care facility and
the relevant area HSC Trust of the vulnerability of that facility caused by
Covid-19. This wil include a recorded assessment of the viability of the facility
to provide a safe level of service, taking account of residents’ il nesses,
staffing issues, etc. The Department of Health, the Public Health Agency
and/or the Regulation and Quality Improvement Authority should be consulted
as required.
2. Trusts and providers wil need to work together to ensure that any staff who are
deployed in the independent sector have a full induction, guidance and skil s
training, and that all relevant registration requirements are followed. This must
include issues such as fire training, how to escalate concerns,
registration with the appropriate regulator, professional policy and practice and
governance of the care home. Trusts and providers wil agree on a framework
and assurance process for this.
3. It is agreed that the requirement for HSC staff to deploy should only arise as a
last resort, following the exhaustion of all other reasonable available avenues
to source staff, including agency staff. This should form part of the recorded
assessment mentioned in point 1. There should be a clear agreement in
advance of the commencement of any redeployment as to the specific role to
be undertaken by a worker.
4. The HSC agrees that before deploying staff to the independent sector,
necessary risk and needs assessments wil be carried out, and recorded to
ensure that there is no unacceptable risk or unreasonable service impediment
in publicly-provided services.
5. Any staff so deployed wil maintain direct and professional line management
from within the trust, continue to report to HSC management, and continue to
be employed under Agenda for Change terms and conditions. They may take
reasonable direction from independent care sector managers to ensure that
they safely discharge their agreed role whilst in any independent care sector
facility or service.
6. Staff redeployed wil continue to carry out their role as HSC employees and are
consequently fully indemnified in their role.
35
7. Staff wil be asked to work within their sphere of competence and an
assessment and agreement of appropriate staf ing levels wil facilitate this.
8. Most tasks carried out by social care staff wil not require any delegation
process and wil be carried out as part of their core duties and functions as
agreed. However if delegation of a complex task to a care worker by
another professional is required the relevant guidance should be followed.
9. Registered nurses and nursing assistants must work to the Northern Ireland
Practice and Education Council “Deciding to Delegate Framework: a
decision support framework for nursing and midwifery”. Nursing support may
be required in a residential home where registered nurses are not normally
employed.
10. It is agreed that in so far as possible, staff are not deployed on their own
and that any deployment should involve a minimum of two staff.
11. Staff deployed wil be given all reasonable information in relation to the status
of the facility they are being asked to attend, including number of deaths,
number of COVID-19 positive patients, number of suspected COVID patients
and patient profile. This should also include comparable staff data. Trusts and
providers shall address any information governance issues.
12. Al staff must be provided with appropriate PPE and supply as required and as
per Government and Trust guidelines
13. The HSC confirms that all Agenda for Change terms and conditions
of employment continue to apply during such redeployments.
14. It is agreed that deployments wil be voluntary and the process set out
at Appendix 1 below should be followed and documented
15. Each HSC area Trust shall have a single point of contact for the independent
care sector in its area and this shall be communicated to al necessary parties.
16. The operation of this agreement shall be monitored by a weekly teleconference
between the Department of Health, HSC employers and Agenda for Change
trade unions. Earlier contacts may be activated if required through existing local
and regional structures.
17. It is recognised that trade union cooperation is dependent on strict adherence
to the provisions of this agreement and trade union side reserve the right to
withdraw from it if HSC are operating in breach of this agreement.
April 2020
36
Appendix 1 –
PROCESS FOR DEPLOYMENT
1. The appropriate area Trust and independent sector contacts wil discuss and
agree any staffing needs that have been identified, in accordance with
paragraph 1 of the agreement.
2. Trusts should prioritise those identified through the HSC Workforce Appeal, and
who have the right skil s, for deployment with independent social and nursing
care providers; or for use as backfil for existing members of staf who can be
deployed. In addition Trusts should work with homes to consider whether any of
the 3,000 volunteers who have registered with Volunteer Now can be deployed
to support social care – but explicitly not in roles that are paid.
3. Staff who agree to redeployment shall be recorded on a deployment register.
This should also include the details of the risk assessments as detailed in
paragraph 1 – 3 of the agreement.
4. Staff who agree to redeploy wil be given the option to be assigned to a
particular facility and reserve the right to refuse same, at any stage, without
detriment.
5. Staff who agree to redeploy should be given as much notice as possible, and
should be informed of the intended duration of the redeployment, to allow them
to make the necessary arrangements at home and in their current workplace.
6. Redeployment should be kept under review and staff should have the options
to give reasonable notice to end the deployment with no detriment.
7. Staff who agree to redeploy should be assigned hours of work in line with their
existing contract of employment unless they agree to vary same. Existing
overtime rates wil be paid for any additional hours worked over full time
hours. Unsocial hours worked wil be paid in accordance with agenda for
change terms and conditions
8. No member of staff wil suffer financial detriment as a result of redeployment
Staff who agree to redeploy wil be paid any additional travel at the full
business rate to the redeployed base from their current workplace.
9. Staff who incur additional travel time as a result of redeployment should have
this paid.
10. Staff who agree to redeploy wil receive subsistence, as per Agenda for
Change terms and conditions, for each day of deployment.
11.At all times, all existing conditions of employment wil be honoured and
respected.
37
Annex B – Pre-admission infection prevention and
control risk assessment proforma
Infection Prevention and Control Pre-Admission/Admission Risk Assessment
To be completed by the Care Home staff pre-assessing/ admitting the person
Person Details
Admitted From Details
Name:
Admitted From:
Date of Birth:
Consultant/GP:
Home Address:
If from Hospital,
reason for admission:
Date of hospital
Date of Admission:
admission if applicable:
Acute Respiratory Illness (ARI)
During admission, has the patient had YES/NO DATE OF ONSET
OR
(IF NOT KNOWN, PROVIDE
Does the patient currently have?
DATE WHEN TEST
PERFORMED)
NEW CONTINUOUS COUGH
WORSENING OF EXISTING COUGH
TEMPERATURE OF 37.8 or ABOVE
LOSS OF TASTE AND/OR SMELL
OTHER RESPIRATORY SYMPTOMS:
(Describe)
Has the patient been tested for?
YES/NO RESULT
FLU-A
FLU-B
RESPIRATORY SCREEN
If yes to any of the above give details on treatment incl. isolation
___________________________________________________________________
__
Is isolation required on admission to the Care Home? (give details, including
38
duration)
___________________________________________________________________
___
Details of any planned follow up e.g. further testing:
___________________________________________________________________
Date of last ‘flu vaccination (obtain details if during ‘flu season): _______________
Infective Diarrhoea and/or Vomiting
Is the Person in Care currently having diarrhoea and/or vomiting
where infection has not been ruled out as cause? YES / NO
Has the Person in Care been in contact with others having
diarrhoea and/or vomiting in the past 72 hours? YES /NO
Have the Person in Care’s family had diarrhoea and/or
vomiting in the past 72 hours? YES / NO
Clostridium difficile
Active C diff: YES/NO History of C Diff: YES/NO No. of Type 6/7 stools in last 72
hours:____
Date of last positive Clostridium difficile toxin specimen:____________
Ribotype:__________
Treatment Received:_______________________ Treatment completed: YES/NO
If treatment ongoing give details:- Treatment details_________________________
Date Commenced___________
Length of Course___________
Details of planned follow-
up:___________________________________________________
39
MRSA/MSSA
Colonised: YES/NO Infected: YES/NO
Date of last positive swab:___________________
Site(s) MRSA
positive:______________________________________________________
Treatment Received:_______________________ Treatment completed: YES/NO
If treatment ongoing give details:- Treatment details_________________________
Date Commenced__________
Length of Course___________
Details of planned follow up:________________________________________
__________________________________________________
COVID-19
Date of last COVID-19 test:___________________ Result: __________________
Date of first positive test:___________________________
Is the person experiencing symptoms: YES / NO
If yes – please
list:_____________________________________________________
Date for routine testing to resume (90 days after first positive
test):_______________
Has COVID vaccine been administered: First Dose: Yes / No
Date_______________
Second Dose: Yes / No
Date
_______________
Type of Vaccine administered _________________________
Known History of Multi-Drug Resistant Organisms or Other Infection Risk
Has the Person a history of having:- ESBL VRE/GRE CPE
Other___________________________________
Other relevant information (e.g. current treatment, planned screening, GIVE
DETAILS OF ANY RECENT ANTIBIOTIC THERAPY):
40
Is the Person / their family aware of any Yes / No / N/A
infection diagnosis?
Environmental Factors
Does the Person require a single room on admission?
Y
e
s
/N
o
Does the Care Home have facility to isolate the Person in a
Yes/No/N/A
single room?
If the Person requires isolation but there is no facility for this,
Yes/No/N/A
can the Person be cohorted with those of same infection status?
Does the care of the Person involved Aerosol Generated
Yes/No/N/A
Procedures? (refer to PHE guidance)
Does the Care Home have sufficient staff to manage any
Yes/No
identified risk?
Person Providing Information:
Person Completing Risk Assessment:
Designation:
Date:
40
Adapted from GAIN Guidelines 2009 & Four Seasons Healthcare Infection Prevention & Control
Pre-admission/admission risk assessment
41
Annex C – Isolation of COVID-19 symptomatic patients
Isolation of residents:-
a. Single case - Isolation of a symptomatic resident: All symptomatic
residents should be immediately isolated for 14 days from onset of symptoms.
b. More than one case - Cohorting of al symptomatic residents:
• Symptomatic residents should ideally be isolated in single occupancy rooms.
• Where this is not practical, cohort symptomatic residents together in multi-
occupancy rooms. Residents with suspected COVID-19 should be cohorted
only with other residents with suspected COVID-19. Residents with suspected
COVID-19 should not be cohorted with residents with confirmed COVID-19.
• Do not cohort suspected or confirmed patients next to immunocompromised
residents.
• When transferring symptomatic residents between rooms, the resident
should wear a surgical face mask.
• Clearly sign the rooms by placing IPC signs, indicating droplet and contact
precautions, at the entrance of the room.
• Staf caring for symptomatic patients should also be cohorted away from other
care home residents and other staf , where possible/practical. If possible, staf
should only work with either symptomatic or asymptomatic residents. Where
possible, staff who have had confirmed COVID-19 and recovered should care
for COVID-19 patients. Such staff must continue to fol ow the infection control
precautions, including PPE as outlined in this document.
Isolation and cohorting of contacts:-
Careful risk assessment of the duration and nature of contact should be carried out,
to put in place measures such as isolation and cohorting of exposed and unexposed
residents. Please refer to the definition of contacts in
Annex D. There are broadly
three types of isolation measures:
•
Isolation of contacts individual y in single rooms for 14 days after last
exposure to a possible or confirmed case: This should be the preferred
option where possible. These contacts should be carefully monitored for any
symptoms of COVID-19 during the 14-day period as described earlier.
42
•
Cohorting of contacts within one unit rather than individual y: Consider
this option if isolation in single rooms is not possible due to shortage of single
rooms when large numbers of exposed contacts are involved.
•
Protective cohorting of unexposed residents: Residents who have not had
any exposure to the symptomatic case can be cohorted separately in another
unit within the home away from the cases and exposed contacts.
•
Extremely clinically vulnerable residents should be in a single room and
not
share bathrooms with other residents.
43
Annex D – Definitions of COVID-19 cases and contacts
•
Possible case of COVID-19 in the care home: Any resident (or staff) with
symptoms of COVID-19 (high temperature or new continuous cough), or new
onset of influenza like il ness or worsening shortness of breath. Also a change in
sense of taste or smell.
•
Confirmed case of COVID-19: Any resident (or staff) with laboratory
confirmed diagnosis of COVID-19.
•
Infectious case: Anyone with the above symptoms is an infectious case for a
period of 10 days from the onset of symptoms and 2 days beforehand.
•
Resident contacts: Resident contacts are defined as residents that:
•
Live in the same unit / floor as the infectious case (e.g. share the same
communal areas).
or
•
Have spent more than 15 minutes within 2 metres of an infectious case.
Close Contact – The full list of close contact criteria includes:
• face-to-face contact including being coughed on or having a face-to-face
conversation within one metre
• skin-to-skin physical contact for any length of time
• been within one metre for one minute or longer without face-to-face contact
• sexual contacts
• been within two metres of someone for more than 15 minutes (either as a one-
off contact, or added up together over one day)
• travelled in the same vehicle or a plane
Staff contacts: Staff contacts are care home staff that have provided care within 2
metres to a possible or confirmed case of COVID-19 for more than 15 minutes. The
same close contact criteria applies as above but they may be exempt from self-
isolation and testing based on a risk assessment by the PHA Duty Room.
•
Outbreak: Two or more cases which meet the case definition of possible or
confirmed case as above, within a 14-day period among either residents or staff
in the care home.
44
Annex E – Contact Points for Independent Sector Staff Testing
NEW: DIGITAL PORTAL for Coronavirus testing for essential or key workers
who are self-isolating because they are symptomatic, or household members
over 5 years of age who are symptomatic.
Essential or key workers can now book tests for themselves and their household via
a new online portal. This wil make the process of getting an appointment quicker and
easier, while reducing the burden on business.
We would encourage you to advise your self-isolating staff to get a test if they or
someone in their household have symptoms.
Please communicate this new service to your eligible workforce and colleagues. This
new service also offers limited home postal test kits which you may be useful for non-
drivers.
The new digital portal has two booking options:
•
Employee Self-Referral Portal:
https://self-referral.test-for-
coronavirus.service.gov.uk/
•
Employer Referral Portal: coronavirus invit
e https://coronavirus-invite-
testing.service.gov.uk/
Organisations need to send registration enquires to be emailed to
xxxxxxxxxxxxxxxxx@xxxx.xxx.xx to get the username and password before using the
portal.
If you need further guidance and support, please contact DHSC at
xxxxxx@xxxx.xxx.xx. Telephone help desk - 0300 303 2713.
For further information please see the Public Health Agency website.
https://www.publichealth.hscni.net/covid-19-coronavirus/coronavirus-national-
testing-programme-key-workers
In addition it is possible to book through Trusts if required:
Belfast Trust
The Belfast Trust has a single telephone line entry to service, triage and booking.
Communication has been issued to al Belfast locality Independent Sector providers
45
giving them the details of how to access the testing and the direct line
telephone number
028 9615 2828 to book appointments.
Northern Trust
Independent Sector Care Workers in the Northern Trust area who require COVID-19
testing should e-mail their details t
o xxx.xxxxxxx@xxxxxxxxxxxxx.xxxxx.xxx
Southern Trust
The Southern Trust are testing all Health Care Workers including Independent Sector
Care Workers, who are symptomatic or have a household member who is
symptomatic. This can be availed of by contacting
xxxxxxx.xxxxxxxxx@xxxxxxxxxxxxx.xxxxx.xxx.
South Eastern Trust
Independent Sector Care Workers in the South Eastern Trust who need advice or
testing should contact
028 92680803 and press option 1 for screening and testing or
option 2 for advice by a registered nurse.
Western Trust
Independent Sector Care Workers in the Western Trust area should inform line
management of COVID related symptoms or symptoms experienced by a Household
Contact, who wil then provide details by email to
xxxxxxx.xxxx@xxxxxxxxxxxx.xxxxx.xxx
46
Annex F – Criteria for shielding vulnerable people in Northern Ireland
Al those in the most at risk criteria wil have received a letter from their GP. Those
most at risk are:
1. Solid organ transplant recipients
2. People with specific cancers
• People with cancer who are undergoing active chemotherapy or
radical radiotherapy for lung cancer
• People with cancers of the blood or bone marrow such as leukaemia,
lymphoma or myeloma who are at any stage of treatment
• People having immunotherapy or other continuing antibody treatments
for cancer
• People having other targeted cancer treatments which can affect the
immune system, such as protein kinase inhibitors or PARP inhibitors
• People who have had bone marrow or stem cell transplants in the last
6 months, or who are stil taking immunosuppression drugs
3. People with severe respiratory conditions including all cystic fibrosis, severe
asthma and severe COPD
4. People with rare diseases and inborn errors of metabolism that significantly
increase the risk of infections (such as SCID, homozygous sickle cel )
5. People on immunosuppression therapies sufficient to significantly increase risk of
infection
6. People who are pregnant with significant heart disease, congenital or acquired
7. People with Motor Neurone Disease
In addition to these criteria, GPs may have written to some individuals they
have identified as at particular risk because of a combination of factors.
Any changes or updates to this list wil be put on the Departmental and
PHA websites.
47
Annex G – Aerosol Generating Procedures (AGPs)
The following procedures are currently considered to be potentially infectious AGPs
for COVID-19:
•
intubation, extubation and related procedures, for example manual ventilation and
open suctioning of the respiratory tract (including the upper respiratory tract)
•
tracheotomy or tracheostomy procedures (insertion or open suctioning or
removal)
•
bronchoscopy and upper ENT airway procedures that involve suctioning
•
upper gastro-intestinal endoscopy where there is open suctioning of the upper
respiratory tract
•
surgery and post mortem procedures involving high-speed devices
•
some dental procedures (for example, high-speed dril ing)
•
non-invasive ventilation (NIV); Bi-level Positive Airway Pressure Ventilation
(BiPAP) and Continuous Positive Airway Pressure Ventilation (CPAP)
•
High Frequency Oscil atory Ventilation (HFOV)
•
induction of sputum
•
high flow nasal oxygen (HFNO)
Neither nebulisation nor long term oxygen therapy are considered AGPs.
48
Annex H – Information Sharing
Privacy Advisory Committee (PAC) Guidance on the disclosure of
COVID-19 infection status & ICO Position on Sharing Information
April 2020
COVID-19. The present COVID-19 pandemic presents a serious threat to life to all
our citizens, particularly older people and people with a variety of health conditions.
The current principal means of public protection is reduction of spread through
reducing contact between individuals, particularly reducing contact with individuals
known or suspected to be infected with the virus.
Patient confidentiality and information sharing. Trust is an essential part of the
service user health care professional relationship and confidentiality is central to
this. Those who have, or may have, COVID-19 infection might be concerned about
their privacy. This guidance sets out how the principles of confidentiality apply when
a health professional is considering disclosing information about the infection status
of patients who have or are suspected of having COVID-19 infection.
Disclosure of COVID-19 infection status
As with all health care information you should make sure that information you have
about a patient’s infection status is at all times protected against improper
disclosure. If you disclose information about a patient’s infection status you must
keep disclosures to the minimum necessary for the purpose.
Disclosing information on a patient’s infection status to others involved in that
patient’s care is part of the usual sharing necessary to provide their care. There may
be other circumstances where the sharing of confidential information is justified
because there is an overriding public interest in protecting life. If the circumstances
permit you should discuss the situation with your line manager or Personal Data
Guardian.
You should inform your patient of the need for this very limited sharing of their health
information to reduce the spread of infection, unless you consider it inappropriate or
impracticable to do so.
Information Commissioner’s Position
The Information Commissioner has provided assurance that she cannot envisage a
situation where she would take action against a health and care professional clearly
trying to deliver care. You can read the statement from the Information
Commissioner’s Office, alongside their Q&A resource. Health and Social Care
regulators across the UK have also published a joint statement.
49
Annex I - Additional sources of training, support and guidance
•
Clinical Education Centre
www.cec.hscni.net
•
Department of Health NI https://www.health-ni.gov.uk/
•
Northern Ireland Social Care Council https://niscc.info/
•
Nursing and Midwifery Council
www.nmc.org.uk
•
Public Health Agency https://www.publichealth.hscni.net/
•
Public Health Agency: Take 5 Steps to Wel -being
https://www.publichealth.hscni.net/publications/take-5-steps-
wellbeing-looking-after-your-mental-health-while-you-stay-home
•
Royal College of Nursing
www.rcn.org.uk
https://www.rcn.org.uk/northernireland
•
World Health Organisation: Mental health and psychosocial
considerations during the COVID-19 outbreak:
ht ps://www.who.int/docs/default-source/coronaviruse/mental-health-
considerations.pdf?sfvrsn=6d3578af2
50
