Infection prevention and control in supported living services and Extra Care housing

Page last updated: 19 July 2023
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Our inspectors use these questions and prompts to look at how well staff and people using supported living services and in Extra Care housing are protected by infection prevention and control (IPC) - key line of enquiry S5.

The questions and prompts are written for our inspectors. We're publishing them here to help providers.

Adult social care inspection information gathering tool: infection prevention and control

Context

We developed an IPC assurance tool for use in care homes during the COVID-19 pandemic. That tool was developed to give us, providers and the public assurance that providers were following the appropriate IPC good practice guidance to keep people safe from potential COVID-19 infection.

We recognised that many people receive care and are exposed to COVID-19 risks outside the care home environment. Throughout the pandemic we, the public, providers and other stakeholders have raised that people who live in supported living services and Extra Care housing schemes are equally vulnerable to the risks of poor IPC practice. This tool has been developed in line with our approach to IPC assurance for care homes as a way to seek and give assurance that where providers have responsibility for IPC they are following best practice guidance and working with other relevant agencies to keep people safe.

This tool will usually be used as part of a focused inspection, where we are looking at the safe key question. However, it can be used for targeted IPC inspections if needed. In line with our existing methodologies, if inspectors identify concerns with the provider’s IPC practice that expose people to the risk of harm, they should refer to our regulations and enforcement policies. The tool is designed to support inspectors to identify good practice and providers may use it to inform their services.

People living in supported living services or Extra Care housing services are receiving care in their own home. Providers delivering these services are supporting people with the regulated activity of personal care. It is important to remember the accommodation in these services is not provided as part of a person’s care; it is entirely separate to the provision of care. The Regulations specifically exclude people’s own homes from the scope of our regulation.

Although we are not inspecting the quality or safety of the premises, we should look at how providers are managing infection prevention and control when they are delivering personal care to people in their own homes.

Supported living services and Extra Care housing services are extremely diverse, as are the needs of the people living there and the support they receive. Some services also deliver support that is outside the scope of regulation. Some people living there will not receive any regulated activities, while for others it will make up only a small part of their package of care. We can only look at the care of people who receive personal care support. It is important to bear this in mind when we are inspecting how care providers are managing IPC.   

The indicators of good practice suggested below must always be read as ‘where the provider is responsible’ to reflect the diversity of the care and support delivered by supported living services and Extra Care housing services. Although best practice guidance is often worded as if the provider has responsibility for accommodation as well as support and care services, ordinarily, care providers have no responsibility for property, accommodation or environment issues in supported living services and Extra Care housing services. In many instances, management’s role will be to develop local procedures and work with the people being supported and, with consent, their families, GP, and housing provider.

Instructions and guidance
  • This form can be completed when you are inspecting infection prevention and control in connection with personal care delivery in supported living or Extra Care housing services.
  • We recognise there is significant variety in the nature of services that make up supported living and Extra Care housing services. This is not a ‘one size fits all’ tool and inspectors will use their professional judgement to make judgements on whether they are assured by the practice observed.
  • You should read the statement of purpose before you inspect. This will confirm the service type, the regulated activities they provide and associated ‘ancillary’ activity, the model of care they practice, and (for EXC and SLS) the type(s) of premises they support.
  • When people are receiving care in supported living or Extra Care housing services, we are not able to inspect the environment or premises. This is the person's own home and is not regulated by CQC. However, we must look at how people are supported to receive safe care and treatment.
  • We can only visit people's home with their consent. We must be mindful of the disruption to people’s lives by having visitors.
  • We will only visit people’s homes where it is safe to do so to collect best practice evidence, and where we have concerns that we may have to take regulatory action to protect people from harm. We must be mindful of any local or national restrictions in place relating to COVID-19 when visiting people’s homes.
  • The tool will help you collate relevant information to provide assurance that a provider has appropriate infection prevention and control (IPC) measures in place. This will support you with inspection report writing.
  • We use the information you gather to produce analysis and intelligence insights and to make it available to other bodies.
  • Add in your notes and observations in the text fields with the evidence used to support your findings. Highlight good practice. Where there are shortfalls (not significant concerns) please support services by signposting them to relevant resources.
  • You should pre-populate the form as much as possible from other sources before the site visit to reduce time spent in people’s homes and minimise exposure to risk. Use information such as the monitoring information, notifications, feedback and enquiries.
  • For the Findings sections, please use the dropdown list to select assured, somewhat assured or not assured for each topic question. It will provide a quantitative measure to understand how well the ‘care at home’ sector is responding to key areas of IPC practice.
  • For the key practice findings, you only need to record key practice and innovation that you think other providers could learn from rather than what we expect providers to be doing in complying with guidance. With poor practice, we want you to highlight failings and concerns that are things that providers may not recognise but has considerable impact on safety in relation to IPC.
  • At the end of the form are a series of closed questions that we want you to answer (mainly) yes or no based on your assessment of the service. This will provide us with a better understanding of implementation of IPC in ‘care at home’ services and allow us to collate and report our findings in a timely manner.

1. Are people supported to minimise the risk of catching and spreading infection?

  • What measures are in place to support people to minimise the risk of catching and spreading infection?
  • What measures are in place to minimise risks when people are unable to follow measures to reduce the spread of COVID-19? 
  • What measures are in place to ensure people who are new to the service are supported to minimise the risk of transferring infection?
Instructions and guidance

What good looks like

  • We must be mindful of people’s rights under the Mental Capacity Act (MCA) 2005 to make unwise or risky decisions. Where providers are responsible for supporting people to manage risks as part of the care package commissioned, we expect them to have taken reasonable steps to mitigate risks where people’s behaviour may place others at risk of harm.
  • Providers support people to follow social distancing, isolating and hygiene practices as much as possible. Providers have made reasonable efforts to ensure people understand the guidance on these measures as it applies to them. Providers should ensure they use the most appropriate communication for each person.
  • Where appropriate providers support people to engage with the vaccination programme. Where providers are supporting people in this way, they have made reasonable efforts to help people to understand vaccination, including using the most appropriate communication for each person.
  • People are supported to minimise the impact on their wellbeing caused by changes to routine, choices, preferences and freedoms.
  • Where people choose not to or are unable to maintain measures to reduce the spread of COVID-19 the provider has taken all reasonable steps to mitigate risks to people and care staff.   
  • The provider takes steps to ensure people are supported to isolate when needed. People in isolation are supported to understand they must not attend communal areas, including shared lavatories and bathrooms. Where this is not possible the provider takes reasonable steps to ensure additional cleaning is implemented where this is their responsibility.
  • People are supported to follow guidance on isolation to minimise the risk of introducing infection to the scheme. Care staff use creative ways to introduce new people to the existing community to ensure people have a positive experience of moving to a new setting.
  • The provider has identified people who are in the clinically extremely vulnerable group. Support is provided in accordance with national guidance.
  • Care plans have been reviewed to consider any additional measures that may be required to ensure safe support in the community. For example, where the provider is responsible for supporting the person to access education, employment or leisure facilities any additional IPC needs have been considered and implemented. The provider has ensured least restrictive options are prioritised to ensure people are able to maintain as much of their support as safely as possible.

Guidance documents

It is important to remember that guidance covering care homes is intended as a reference point for providers, rather than guidance they must follow.

2. Are people supported with safe visits?

  • What measures are in place to minimise the risk of visitors catching and spreading infection?
  • What suggested procedures do people follow during the visit? How is this appropriately communicated to people? Do the procedures appear to be complied with by visitors?
  • How are people supported with alternative arrangements to face to face visits if needed?
Instructions and guidance

What good looks like

  • Where the provider is responsible for supporting people who receive personal care to manage their personal relationships and risks, they have taken reasonable steps to ensure the risks of having visitors who may catch and spread infection are understood and mitigated.
  • The decision on whether to allow visitors access to their home is ultimately the person’s own decision.
  • We must be mindful of people’s rights under the Mental Capacity Act (MCA) 2005 to make unwise or risky decisions. In shared houses where one person’s decision making may place others at risk of harm, we expect providers to have taken reasonable steps to mitigate these risks.
  • We expect providers to have discussed the infection risks (including any local or national COVID-19 advice) with people in an appropriate way. The provider should work with the person to agree safe visiting arrangements.
  • Visiting policies are developed with due consideration of local and national public health advice.
  • The provider follows relevant COVID-19 testing guidance. This includes staff testing requirements as well as guidance on testing for people using the service and visitors. It is important to remember that for people using the service or their visitors, having a test is personal choice. Where a member of staff, a person using the service or visitor declines to be tested, appropriate risk assessments are made in line with current guidance.
  • It is not the responsibility of providers to provide Lateral Flow Device (LFD) tests to visitors. Some providers may choose to offer this where they have LFD tests available, but others may not have the LFD resource available to do this.
  • Where they are responsible, providers work with relevant housing providers, people and visitors to plan visiting times to limit the number of people needing to access communal areas (when needed to maximise people's safety) and accommodate effective cleaning of the environment.
  • Where they are responsible, providers encourage people and visitors to avoid contact with people they are not specifically visiting and to minimise contact with staff.
  • The provider has worked closely with the housing provider to ensure facilities are in place to wash hands for 20 seconds or use hand sanitiser in communal areas and on entering and leaving the service.
  • Where responsible, the provider takes reasonable steps to work with people and visitors to encourage the wearing of face coverings in circumstances where this is advised by guidance and hand washing before and after mask use. Visitors are encouraged to wear personal protective equipment (PPE) in line with the guidance for DCA staff. It is not the responsibility of providers to provide PPE to people using the service and visitors. Some providers may choose to do this where they have PPE available, but others may not have the PPE resource available to do this.
  • Providers work closely with housing providers to enable visitors to be screened for symptoms before entering the service.
  • Providers work closely with housing providers to ensure prominent signage and instructions are on display, particularly in communal areas to promote safety. Signage should be in an accessible format and only displayed in people’s own homes with their agreement.
  • Where providers are responsible for supporting people with their relationships they take reasonable steps to ensure information is accessible and easily available on arrival or in advance to enable visitors to follow guidance, procedures and protocols to encourage compliance with IPC.
  • Providers support people with alternative forms of maintaining social contact for friends and relatives. For example, using video calls, emails, meeting in outdoor public places in line with the local or national restrictions. Remote considerations are also considered by other visitors such as professionals and clinical consultants.

Guidance documents

It is important to remember that guidance covering care homes is intended as a reference point for providers, rather than guidance they must follow.

3. Do care staff use PPE effectively to safeguard staff and people using services?

  • Where and how are care staff donning and doffing PPE? How is PPE disposed of after use?
  • Do the levels of PPE used comply with current guidance?
  • What specific PPE training has been provided during the pandemic?
  • People using the service may be fearful or anxious seeing care staff wear PPE or it could make communication difficult. What measures are in place to support communication and reassurance?
Instructions and guidance

What good looks like

  • Use of PPE is in accordance with current government guidelines COVID-19 personal protective equipment (PPE):
    • People have been supported to identify areas for staff and visitors to don and doff their PPE. These areas are clearly identified and ideally separate areas for donning and doffing.
    • The provider has worked with the housing provider to ensure, where appropriate and possible, signage on donning and doffing PPE and handwashing is visible in all communal areas, including for visitors.
    • Where possible, the inspector observes staff putting on and taking off PPE as per guidelines.
    • Where possible, the inspector observes staff following good hand washing and respiratory hygiene (covering mouth and nose with tissue when coughing or sneezing) practices using appropriate products.
    • Disposal of used PPE prevents cross-contamination and follows relevant protocols, in particular single use items and how PPE is disposed of safely.
  • Staff wear PPE in line with the guidance for domiciliary care staff when delivering personal care to all people.
  • Staff wear PPE in line with guidance where recommended appropriate social distancing cannot be maintained or achieved.
  • Staff wear PPE in line with guidance where someone is isolating irrespective of social distancing advice.
  • The provider has robust systems in place to ensure government PPE guidance is being followed across the services they support.
  • Staff have engaged with IPC training.
  • The provider has assessed the impact on people of how PPE may cause fear and anxiety for them, particularly those who have limited mental capacity and has mitigated these concerns using the COVID-19 risk reduction framework.
  • The provider has addressed issues where PPE may not fit appropriately because of staff gender or other protected characteristics.
  • The provider has assessed the impact of staff moving between people receiving care, different households and different environments during their working day and how this may affect their PPE requirements.
  • The provider has considered, and risk assessed PPE needs of staff if people using the service have been admitted to hospital and are being discharged back to their homes.
  • Staff have sufficient supply and access to appropriate PPE. This includes where staff are funded via direct payments and personal budgets.
  • The provider has made arrangements with other providers who also support people within the scheme to ensure PPE is always available.

It is not the responsibility of providers to provide PPE to people using the service and visitors. Some providers may choose to do this where they have PPE available, but others may not have the PPE resource available to do this.

Guidance documents

4. Is there adequate access and take up of testing for care staff and people using services?

  • How do staff and people receiving care access regular testing?  What is the frequency of testing? 
  • What does the provider do if someone becomes symptomatic or when a positive test occurs? 
  • What does the provider do if an outbreak among people using the service or staff is identified?
  • What does the provider do if people or staff refuse a test? Does the provider make reasonable efforts to understand why they refuse?
Instructions and guidance

What good looks like

  • The provider understands the current eligibility for routine testing and has referred themselves into the testing system (if not referred by the local authority).
  • Routine testing scheme for all staff has been implemented.
  • Routine testing scheme for people who receive support has been implemented.
  • The provider has made reasonable efforts to ensure people understand the need for testing and the testing process. Providers should ensure they use the most appropriate and accessible communication for each person.
  • Information for people on when and how they would be able to access testing has been made accessible to people.
  • Appropriate consent is in place for people using the service, where people do not wish to be tested, they are supported to understand why testing is deemed important. Any refusals are risk assessed to ensure they do not impact on others receiving care. Where people lack capacity to consent to testing the provider has followed the MCA and best interest principles.
  • When people need support to undertake testing, they are supported by staff who have been appropriately trained to undertake testing.
  • Staff understand how to identify symptoms of COVID-19 in the people they support. Staff understand how the people they care for express or communicate pain, discomfort or feeling unwell.   
  • Providers have provided accessible information to people to support them to self-identify symptoms.
  • Risk assessments have been carried out on people using services and staff belonging to higher risk groups and actions have been taken to mitigate the risks.
  • All staff have a test without delay once they become symptomatic. Staff who have been exposed to with people in their own households displaying symptoms COVID-19 have also had a test where recommended by guidance. Frequency of testing follows current guidance.
  • Managers and staff have processes in place to ensure they know how to access the online self-referral portal or obtaining login details via email portalservicedesk@dhsc.gov.uk
  • Providers have clear processes in place to respond to positive test results in staff team, including how this is explained to people and their visitors. The provider takes reasonable steps to support staff and people using the service to follow NHS Test and Trace guidance and requirements.
  • Providers have followed relevant COVID-19 guidance and worked with people and their visitors to agree processes for positive test results. People have been supported to understand the importance of isolating to break the chain of infection. People are prepared for increased PPE and reduced face to face contact if they test positive. The provider has contingency arrangements in place to minimise the impact of isolation on people’s wellbeing and mental health.

Guidance documents

5. Are people supported to maintain safe levels of hygiene to minimise the risk of infection?

  • Where providers are responsible, what measures are in place to support people to keep their home environment hygienic and minimise the risk of infection?
  • What measures are in place (including working with the housing provider) to keep communal areas hygienic and minimise the risk of infection?
  • How have communal indoor and outdoor spaces been optimised to use safely?
Instructions and guidance

What good looks like

  • The provider has a designated lead for cleaning and decontamination. They take responsibility for escalating IPC related hygiene concerns where people need additional support to maintain their environments and lead on the relationship with the housing provider where necessary.
  • Providers have worked with people and housing providers to ensure communal areas are kept clean and risks of contamination are mitigated.
  • Where people are responsible for the hygiene of their environment any support plans they have in place have been reviewed and updated to reflect any support they may need to ensure their homes are hygienic.
  • The provider has considered any contingency support that people may need to maintain their environment should they contract COVID-19. The provider has got a plan in place to refer the person for additional support if their needs change.
  • Where the provider is responsible, communal areas are subject to regular and enhanced cleaning.
  • Where the provider is not responsible for maintaining communal areas they have worked with the housing provider to ensure, where possible, rooms are designated for specific activities (such as visiting, testing or PPE donning and doffing). The provider has worked with the housing provider to promote that these are subject to regular enhanced cleaning.
  • Where possible, has the provider worked with the housing provider and people living in the building to implement a one-way systems for visitors and staff?
  • People are supported to understand the importance of effective ventilation. Information about the importance of ventilation has been made available in accessible formats.
  • Where the provider is responsible for cleaning, there are clear schedules in place, which include the frequency of cleaning of high touch areas. Records show compliance with the cleaning schedule.
  • People are involved in creative ways in ensuring the service is clean and kept clean.
  • People who are symptomatic are supported to follow best practice guidance around their laundry. The provider has considered if people will need additional support with their laundry if they develop symptoms and has taken steps to ensure this support is available.
  • Where laundry facilities are shared (either because an ordinary house share arrangement, or because they are communal facilities in a housing scheme) appropriate enhanced cleaning of the facilities has been facilitated. The provider has introduced a booking system to ensure social distancing and good IPC practice in the laundry.
  • People are supported to understand and follow good practice guidance for waste management, including storage of contaminated items within people’s homes before going to shared refuse facilities. People are supported to double bag potentially contaminated waste and store it for 72 hours.

Guidance documents

6. Do staff training, practices and deployment show the provider can prevent transmission of infection and manage outbreaks?

  • How is staff movement and transmission between people and households minimised? How have staff rotas, shift patterns, break time arrangements, handovers changed to improve IPC?
  • If agency staff are used, how is their compliance with IPC measures and not working between other households or services assured?
  • What recent IPC training has been given to staff to provide safer care?
  • Has the provider experienced COVID-19 cases, if so was there any learning from this?
  • How is staff wellbeing supported, including becoming unwell, sick leave and returning to work safely?
  • How is the registered manager being well supported in their role to be resilient and managing IPC risks effectively?
Instructions and guidance

What good looks like

  • All staff in high risk groups such as BAME and clinically 'extremely vulnerable' have been risk assessed, and adjustments have been made.
  • Risks associated with staff moving between households have been identified with measures in place to mitigate these risks. Where staff normally work across multiple schemes staff movement has been limited to a main place of work.
  • Risks associated with the use of agency staff have been identified and mitigated. The provider has ensured that agency staff are not working in care homes or multiple settings.
  • In larger settings ‘cohorting’ staff to individual groups of people or floors is practised.
  • The use of public transport by people and their staff has been subject to a risk assessment.
  • Staff have undertaken training and are competent in IPC.
  • Where premises have designated areas for staff to use and take their breaks shifts are staggered so social distancing can be maintained during break times.
  • Handovers are done virtually where possible, using secure messaging apps such as WhatsApp.
  • Staff are deployed creatively and flexibly to maximise people’s wellbeing, independence and freedom and maintain as much of their usual support as safely as possible.
  • Staff are trained and know how to immediately instigate full infection control measures to care for a person who develops symptoms, who tests positive or who has been exposed to the virus to avoid the virus spreading to other people and staff.
  • Staff who are isolating in line with government guidance receive their normal wages while doing so.

Guidance documents

To complete after site visit

7. Is IPC policy up to date and implemented effectively to prevent and control infection?

  • Are infection risks to people thoroughly assessed and managed? What action has been taken to consider and reduce any impact to people and staff who may be disproportionately at risk of COVID-19? (BAME, extremely clinically vulnerable, learning disabilities, dementia)
  • What changes have been made following the most recent audit?
  • What contingency planning is in place to address future coronavirus and other infection outbreaks, and winter pressures?
Instructions and guidance

What good looks like

  • There is a designated IPC lead who is sufficiently knowledgeable to fill this role. Evidence of effectiveness includes knowledge of current guidance, dissemination to staff and others, liaising with relevant agencies, communication and transparency with people using services, the family and friends.
  • The provider demonstrates a good understanding of what and how to access local IPC resources (e.g. local health protection team) when they need advice and support.
  • IPC policy is up to date and in line with the code of practice and has been audited during the pandemic to reflect best practice.
  • Staff know how to immediately instigate full IPC measures to care for people who develop symptoms to avoid the virus spreading.
  • Information is available for people and their visitors on how to raise concerns or complaints around IPC practice if they think it is unsafe or not effective without fear or discrimination. There is evidence of responsive action to concerns made. Where appropriate the provider has facilitated people to raise concerns with related providers or the housing supplier.
  • Providers have contacted their local health protection team (in line with guidance) if they suspect a new outbreak.
  • All equipment used to support the monitoring of people (such as pulse oximeters) meets infection control and decontamination standards, guidance and code of practice.
  • In compliance with the code of practice, there is a decontamination policy in place that  covers what to do if there is a spillage of blood or body fluids.
  • The provider has due regard to the MCA and has considered if applications to the court of protection may be appropriate if changes made to people’s care in response to COVID-19 amount to a restriction of their liberty.
  • The provider has a clear policy and procedure, updated in light of the pandemic, to advise staff how to respond to a death in the service.

Guidance documents

Other resources

SCIE, Skills for Care, British Geriatric Society, BILD, CPA,  ADASS

8. Key practice findings and mandatory questions

We record:

  • good practice and innovation we think other services could from
  • unexpected failings and concerns that providers may not recognise but have a considerable impact on safety in relation to IPC

Additional mandatory questions

  • Does the provider have sufficient and adequate supply of PPE that meets current demand and foreseen outbreaks?
  • Are staff using PPE correctly and in accordance with current guidance? 
  • Has the provider ensured its staff have received appropriate PPE training?
  • Does the provider know where to go for advice should there be an outbreak – which authorities and what their role and responsibilities are?
  • Is the provider participating in the testing program that is currently provided for people using the service and staff members?
  • Does the provider understand the principles of isolation, cohorting (staff) and zoning (communal areas) appropriately?
  • Does the provider support isolation, cohorting (staff) and zoning (communal areas) where possible?
  • Does the provider support safe visits to people using the service?
  • Has the provider adequately taken measures to protect clinically vulnerable groups and those at higher risk because of their protected characteristics (BAME, physical and learning disabilities)?
  • Does the provider have details of healthcare professionals involved in people’s care?
  • Has the provider supported people to access clinical support as appropriate?
  • Has the provider accessed additional support and resources?

See also

Infection prevention and control in care homes