Guidance

[Withdrawn] Personal protective equipment: resource for care workers working in care homes during sustained COVID-19 transmission in England

Updated 16 August 2021

This guidance was withdrawn on 4 April 2022

This guidance has been superseded by information in Infection prevention and control in adult social care: COVID-19 supplement.

Who this guidance is for

This guidance is intended for all care workers working in care homes in England. It can also be applied to visitors or essential care-givers within the care home setting.

This guidance is of general nature and is intended to be compatible with legislation. In the case that information in this guidance differs from a requirement in legislation, the legislation should be followed. The guidance remains under review and may be updated in line with the changing situation as required.

Employers and managers must provide workers with safe conditions of work, complying with all applicable legislation, including the Health and Safety at Work Act 1974 and the Health and Social Care Act 2008: code of practice on the prevention and control of infections.

This guidance has been developed in consultation with the Department for Health and Social Care (DHSC) personal protective equipment (PPE) Task and Finish group, which represents the adult social care sector.

What has changed

From 16 August, the isolation requirements for fully vaccinated people identified as a contact of a COVID-19 case in England have changed.

Fully vaccinated means that you have been vaccinated with an MHRA approved COVID-19 vaccine in the UK, and at least 14 days have passed since you received the recommended doses of that vaccine.

Requirements for fully vaccinated staff who are identified as contacts of a case of COVID-19 are detailed in guidance on the management of staff and exposed patients and residents.

Requirements for fully vaccinated residents who are identified as contacts of a case of COVID-19 are detailed in guidance on admission and care of residents in a care home.

Requirements for fully vaccinated essential care givers who are identified as contacts of a case of COVID-19 are detailed in guidance on visiting arrangements to care homes.

Due to the vulnerability of residents in care home settings, there is no change to PPE advice.

What you need to know

Care home providers should consider how to put this guidance into practice in their specific context. This guidance provides a minimum standard on the use of PPE and face masks. Employers have duties concerning the provision and use of PPE at work. All organisations are responsible for ensuring safe systems of work, including the completion of a risk assessment approved through local governance procedures. This includes those that adopt practices that differ from those recommended or stated in the national guidance.

For the purposes of this document, the term PPE is used to describe products that are approved by the Health and Safety Executive (HSE) under PPE legislation. The Medicines and Healthcare products Regulatory Agency (MHRA) regulates medical products and medical devices, for example the Type I and II masks used in this guidance as source control. Both PPE and medical devices are appropriate as solutions in managing the COVID-19 pandemic, depending on correct usage.

In this guidance, a session refers to a period of time where a care worker is undertaking a duty which is not delivering direct personal care to a COVID-19 positive resident or a resident with respiratory symptoms in a specific setting or environment. The session ends when the care worker finishes that task and leaves that care setting or environment, or takes a break. Sessional use is also when the care worker is providing continuous care for a cohort of residents who are not COVID-19 positive or have respiratory symptoms.

Effective and appropriate use of PPE is one of several actions to reduce the transmission of COVID-19. The prevention and control of COVID-19 requires other measures including source control, enhanced cleaning, ventilation, keeping a safe distance and hand hygiene.

PPE should be used correctly and is only effective when combined with:

• cleaning your hands regularly and appropriately for at least 20 seconds
• respiratory hygiene (‘catch it, bin it, kill it’) and avoiding touching your face with your hands
• following standard infection prevention and control precautions
• following the correct technique for putting on and taking off PPE
• safe disposal of used PPE

Perform hand hygiene immediately before every episode of care and after any activity or contact that potentially results in your hands becoming contaminated. This includes the removal of PPE, equipment decontamination and waste handling. Follow your organisation’s policy and procedures on hand hygiene and hand maintenance (for example, keeping nails short, using moisturiser to keep skin on hands intact and not wearing false nails or nail varnish).

Follow advice for the general public when outside work (that is, before work duties commence and after work duties end).

This guidance should be read in conjunction with admission and care of residents in a care home during COVID-19, visiting arrangements in care homes, and reducing risk in adult social care and management of staff and exposed patients and residents in health and social care settings.

Determining the PPE to use

It is the duty of your employer to undertake the risk assessment in consultation with employees. However, you also need to take precautions to protect your own health and to prevent passing on infection to people you care for and work with. You should work with your employer to risk assess the use of PPE regardless of whether the person you are caring for has any COVID-19 or other respiratory symptoms. This will also need to be based on the personal needs and assessment of the resident. The type of PPE required will depend on the tasks you are carrying out.

Risk assessment involves assessing the likelihood of encountering a person with COVID-19, considering the ways that infection might be passed on and how to prevent this, including through use of PPE.

To help you with the risk assessment, this guidance covers what PPE to wear in 3 main scenarios:

• providing direct personal care
• other contact within 2 metres of anyone else
• carrying out domestic duties or other activities

The recommended items of PPE are described for each of these scenarios. There are also sections on putting on and removing PPE, handling waste (including PPE), cleaning eye protection between uses and aerosol generating procedures (AGP).

You should discuss situations where you are concerned about your own safety with your manager. If, after raising a concern, you believe you are being asked to work in a way that is not safe, you should seek support, including from your union if you are a member, and consider whether making a disclosure to the Care Quality Commission (CQC) is appropriate. There is further guidance available on raising a concern with the CQC. Health and Safety Executive (HSE) regulates worker safety so if you have concerns regarding your own safety, you should contact HSE here – Contact HSE - Reporting a health and safety issue.

Where you may have difficulty wearing masks as advised by this guidance, this should be discussed confidentially between you, your employer and an occupational health representative (which may be your GP). If a mutually agreeable position cannot be reached to comply with the guidance, employees can refer to the Advisory, Conciliation and Arbitration Service (ACAS) for resolution, who can be contacted through their website.

See also making your workplace COVID-secure during the coronavirus pandemic and PPE guidance from HSE.

There may be circumstances where following this guidance presents challenges in caring for the resident, for example, where lip-reading or facial recognition is especially important for care. This should be discussed with your manager.

Residents who are clinically extremely vulnerable

The same PPE recommendations apply regardless of whether the resident is clinically extremely vulnerable or not.

See guidance on shielding and protecting people defined on medical grounds as extremely vulnerable.

Residents with learning disabilities, mental health problems, autism and dementia

There may be challenges in following PPE recommendations when providing care particularly for people with learning disabilities, mental health problems, autism and dementia. For example, face masks may cause distress which can result in behaviour that may cause harm to the resident or others.

A comprehensive risk assessment should be undertaken for each resident identifying the specific risks for them and the carer to develop appropriate strategies to safely manage those risks. It is important that in doing this you do not alter the recommended PPE items in any way as this could reduce their effectiveness in protecting staff or the people you are providing care for. It is important to seek advice and support from your management team at an early stage if the measures show signs of causing distress for individual residents.

See guidance for care staff supporting adults with learning disabilities and autistic adults for more information.

Residents who have been vaccinated

The COVID-19 vaccination programme has been rolled out across the country with the most high-risk groups being prioritised first. This included care home residents and care staff. Vaccination helps to protect those who are at most risk from serious illness or death from COVID-19. However, it is still possible for fully vaccinated individuals to catch and pass on COVID-19, therefore it is vital that you continue to adopt practices that limit infections. This includes the continued use of PPE.

Providing direct personal care to a resident

Table 1: PPE recommendations when within 2 metres of a resident and carrying out direct personal care (for example, physical care) to someone who is COVID-19 positive or who is isolating

Disposable gloves (vinyl, latex or nitrile)	Yes
Disposable plastic apron	Yes
Single use fluid-repellent surgical mask (Type IIR)	Yes
Eye protection (single use or decontaminate as per manufacturer’s instructions)	Yes

Table 2: PPE recommendations when within 2 metres of a resident and carrying out direct personal care (for example, physical care) where there is a risk of contact with respiratory symptoms or body fluids (for example coughing, sneezing, spitting). This is usually within the resident’s own room

Disposable gloves (vinyl, latex or nitrile)	Yes
Disposable plastic apron	Yes
Single use fluid-repellent surgical mask (Type IIR)	Yes
Eye protection (single use or decontaminate as per manufacturer’s instructions)	Yes

Table 3: PPE recommendations when within 2 metres of a resident who has no symptoms and a negative test for COVID-19, and carrying out direct personal care (for example, giving physical care). This is usually within the resident’s own room

Disposable gloves (vinyl, latex or nitrile)	Yes
Disposable plastic apron	Yes
Type IIR surgical mask (can be left on when task is completed unless it has become contaminated)	Yes
Eye protection	No

These recommendations apply:

• to direct personal care (for example, giving physical care, assistance using the toilet or commode, changing dressings) and when unintended personal contact with residents is likely (for example, when caring for residents with challenging behaviour)
• to all staff involved in delivering personal care including essential care givers or visitors if they are carrying out personal care (for example, giving physical care) within 2 metres usually within the resident’s own room

Eye protection is needed when one or more of the following occurs:

• when you have risk assessed that there is a risk of splashing of body fluids or contamination to the eyes. This includes when someone coughs, sneezes, spits near your eyes
• the resident has had a positive COVID-19 test within 14 days, the resident has new respiratory symptoms (for example coughing, sneezing)

Extra precautions need to be taken when undertaking aerosol generating procedures (AGPs). Please see the section on AGPs about the PPE you would need to use.

Disposable gloves

Disposable gloves are single use. When worn correctly, single-use gloves protect you from contact with the resident’s body fluids and secretions.

Dispose of gloves immediately after completion of a procedure or task and after each person being cared for, and then wash and dry your hands. If handwashing facilities are not available, hands can be cleaned using hand sanitiser prior to putting on another pair of gloves if required. Take care not to touch your face, mouth or eyes when you are wearing gloves.

The type of glove used should be based on a risk assessment of the task being carried out. There are a number of different types of gloves: vinyl, nitrile and natural rubber latex. Employers should consider carefully the risks when selecting gloves for use in the health and social care sector. HSE has provided specific guidance on selecting latex gloves and recommends following HSE’s glove selection guidance when considering glove use in the workplace (latex or otherwise).

Vinyl gloves provide sufficient protection for most duties in the care environment, providing the gloves fit. If there is a risk of gloves tearing, or the task requires a high level of dexterity, or an extended period of wear, then an alternative better fitting glove (for example, nitrile) should be considered.

If a change of gloves is required during a task because the glove is torn or punctured, wash and dry your hands after removal of the original gloves. Hands should be thoroughly dried to make the donning of new gloves easier, reducing the risk of gloves tearing before donning a clean pair.

Employers need to consider the type of different gloves available for the duties you are doing. This includes the gloves required in relation to cleaning products. You should follow the manufacturers’ instructions.

Disposable plastic aprons

Disposable plastic aprons are for single use only. Wear disposable plastic aprons when providing direct personal care to a resident and when exposure to body fluids is likely. Dispose of the apron immediately after providing care for each resident and after completion of a procedure or task. Hands should be washed and dried thoroughly immediately after removal.

Fluid-repellent (Type IIR) surgical mask

Fluid-repellent surgical masks are Type IIR surgical masks that protect the wearer by providing a fluid repellent barrier between the wearer and the environment. Therefore, they provide additional protection to you from respiratory droplets produced by residents (for example, when they cough or sneeze) and protect residents by minimising the risk of you infecting them via secretions or droplets from your mouth, nose and lungs.

After providing direct personal care for to a resident with respiratory symptoms (for example coughing, sneezing) or who has had a positive COVID-19 test in the last 14 days, you should remove and dispose of the mask and apply a new Type IIR surgical mask before providing care for the next resident or carrying out another duty.

You should not touch your face mask unless to put it on or remove it. If you touch the front of the mask by mistake while you are carrying out a task, you should wash or sanitise your hands immediately. Make sure the mask fits as snugly to the face as possible. Consider trying a different mask if the fit is poor.

If you have provided direct personal care to a resident who has tested negative for COVID-19 and does not have respiratory symptoms (for example, coughing, sneezing), and assuming your mask is not damp, soiled or worn for more than 4 hours, you can wear it for the next resident contact. However, you will need a clean change of apron and gloves for any care or task where PPE is required.

Eye protection

It is recommended to use eye protection when:

• providing care within 2 metres to a resident who has tested positive for COVID-19 and is within the 14-day isolation period
• or who has been required to isolate as a contact of someone who has COVID-19
• or has respiratory symptoms and is coughing, sneezing or tends to spit

In this situation, there is risk of droplets or secretions from the resident’s mouth, nose, lungs or from body fluids reaching the care worker’s eyes.

Eye protection can either be a face-shield (visor) or goggles. It may be designed for single use or designed to be used more than once if decontaminated correctly between uses. Eye protection such as visors provide a barrier to protect your eyes from respiratory droplets (for example, produced by a resident with respiratory symptoms), and from splashing of secretions (for example, of body fluids or respiratory secretions). Eye protection should cover the eyes completely. It should be used in conjunction with a Type IIR mask. Eye protection should not be worn instead of a mask.

Use of eye protection should be discussed with your manager and you should have access to eye protection while you are working. Personal prescription glasses are not a substitute for eye protection, you will need to wear a visor or goggles as well.

If you are provided with goggles or a visor that is reusable, you should be given instructions on how to clean, disinfect and store them in accordance with the manufacturer’s instructions or local infection control policy. Please see section on using PPE: cleaning eye protection between uses.

If eye protection is labelled as single-use, it should be used for a single task (that is, a single episode of an individual resident’s personal care) and should then be disposed of after removal. Please see section on using PPE: what to do with waste including PPE.

Other contact within 2 metres of anyone else

Table 4: Recommendations when within 2 metres of an individual but not carrying out direct personal care*

Type I or II surgical mask or Type IIR	Yes
Disposable gloves (vinyl, latex or nitrile)	No
Disposable plastic apron	No
Eye protection (unless there is a risk of contact with body fluids, risk of contact from residents who may be coughing, sneezing or spitting or a risk of splashing from cleaning products)	No

*For example, working in communal areas such as the lounge, undertaking a group activity, doing the tea round, delivering linen to client rooms, attending staff handovers.

These recommendations apply:

• to all staff members who may be within 2 metres of residents, visitors or other staff

Eye protection is needed when you have risk assessed that there is a risk of splashing of body fluids (including respiratory secretions) from:

• residents who may be coughing, spitting or sneezing into your eyes
• residents who have had a positive COVID-19 test in the last 14 days
• residents who have been required to isolate as a contact of COVID-19 but will not cooperate with isolation requirement

If you have risk assessed that there is a risk of splashing of bodily fluids onto your mask, then a Type IIR face mask should be worn.

Type I or II mask

If you are likely to have contact within 2 metres of anyone else (residents, visitors or other staff), you should wear a Type I or II mask.

Type I or II masks help reduce spread of COVID-19 by preventing you from passing on the virus to other people (for example, through respiratory droplets or via your hands after touching your mouth or nose and then touching surfaces). The face mask can be worn for the duration of that activity. This is referred to as sessional use.

If Type IIR face masks are more readily available and there are no supply issues for their use as PPE, then they can also be used for the purposes of source control as an alternative to Type I or II masks.

Type IIR masks may also be worn if the wearer is wearing it for an extended period of time while carrying out duties that do not include caring for residents who are COVID-19 positive or with respiratory symptoms. If you have risk assessed that there is a risk of splashing of bodily fluids onto your mask, then a Type IIR should be worn.

The face mask can be worn for a maximum of 4 hours and should be changed when damp, soiled, contaminated or uncomfortable. If you need to eat or drink, you should remove your mask, dispose of it and clean your hands. Once finished eating or drinking, put on a new mask.

Carrying out domestic duties or other activities

Table 5: Recommendations when more than 2 metres from a resident undertaking domestic duties or other activities and not delivering personal care (for example cleaning, laundry, tidying)

Disposable gloves (vinyl, latex or nitrile) (unless there is a risk of contact with body fluids or contaminated waste)	No
Disposable plastic apron (unless there is a risk of contact with body fluids or contamination of clothing)	No
Type I or II surgical mask or Type IIR (sessional use may apply)	Yes
Eye protection (unless you are carrying out domestic type duties within a resident’s room where the resident has had a positive COVID-19 test within 14 days and is isolating, or has respiratory symptoms or is unable to maintain a safe distance)	No

These recommendations apply:

• where no personal care is being undertaken (if direct personal care is being delivered, please refer to Tables 1, 2 and 3 above)
• whatever your role in care (these recommendations therefore apply to all staff)

If you are unable to maintain 2 metres distance from anyone in the care home who has respiratory symptoms or has had a positive COVID-19 test within the past 14 days, follow the recommendations in the section above on ‘Providing direct personal care to a resident’.

If you are undertaking cleaning duties, then you should use usual household products, such as detergents and bleach, as these will be very effective at getting rid of the virus on surfaces. The regularity of cleaning frequently touched surfaces should be increased.

Disposable gloves

Staff may wish to wear disposable gloves for routine cleaning, but for the purpose of PPE, they are not needed unless there is a risk of contact with bodily fluids. If chemicals are being used as part of a decontamination schedule, carry out a COSHH assessment and wear the correct PPE.

If a change of gloves is required during a task because the glove is torn or punctured, then wash your hands thoroughly making sure they are completely dry before putting on new gloves.

Providers need to consider the type of different gloves available for the duties you are doing. This includes the gloves required in relation to cleaning products. The manufacturers’ instructions should be followed.

Disposable plastic apron

Disposable aprons are only required to protect your uniform from splashes from chemicals, disinfectants or blood and body fluids or if the area you are working in has a resident who is within 14 days of a positive COVID-19 test or is in isolation.

Type I or II surgical mask

Type I or II surgical masks are recommended when carrying out domestic duties as these provide source control (for example, protect others from you).

A Type I or II mask can be worn sessionally while undertaking domestic duties. The maximum period of time for wearing a Type I or II mask is 4 hours.

You should remove and dispose of the mask if it becomes damaged, visibly soiled, contaminated, damp, or uncomfortable to wear. Do not touch your face mask unless it is to put it on or remove it.

Type I or II masks are sufficient for domestic duties. However, if the care home already has a supply of fluid-repellent (Type IIR) surgical mask, these are acceptable to use for this purpose.

Eye protection

You need to risk assess the need for eye protection when carrying out domestic duties.

Eye protection is not required for infection prevention reasons unless you are carrying out domestic duties in a room where there is a resident who is COVID-19 positive or has respiratory symptoms or is unable to maintain a safe distance.

Ensure the eye protection is used in line with the manufacturers’ guidance according to whether it is a disposable item of PPE or is a reusable item. Eye protection may be indicated if there is a risk of splash hazard from the cleaning products.

Putting on and removing PPE

You need to follow a safe procedure when putting on and taking off your PPE. Where you put on and remove your PPE will depend on the risk. It is better to put on all of your PPE before entering the room of a resident who has had a positive COVID-19 test in the last 14 days or who has been required to isolate or who has respiratory symptoms.

The place where you remove your PPE, and the order in which you remove it, is critical to protect yourself. On completion of a task for a resident who has had a positive COVID-19 test in the last 14 days or who has been required to isolate or who has respiratory symptoms, only the gloves and apron should be removed within the room. The mask and eye protection should be removed at a designated location after leaving the room. For other residents, you should remove your PPE at least 2 metres away from the person for whom you have been delivering personal care. For more information, see the video on putting on and removing PPE. Your manager will need to decide the best place to do this depending on the care needs of the resident and the built environment.

PPE should be worn until the end of the care episode and removed at an identified place where aprons and gloves can be safely doffed and disposed of and hands can be decontaminated. This will be dependent on the environment and layout of the care home (for example sluice or resident bathroom). If you are unsure seek your manager’s advice. If a resident is in isolation for infection reasons, local procedures for removal and disposal of used gloves and aprons should be followed.

What do to with waste including PPE

Waste generated from people with symptoms of (or who have tested positive for) COVID-19, and are still in isolation, needs to be managed carefully.

For care homes that have an offensive (tiger stripe) waste stream, PPE and waste from personal care (for example soiled wipes and continence products) should be placed in a tiger striped (offensive) waste bag and be disposed of as healthcare waste (for example, an external lockable yellow wheelie bin) for collection by a hygiene waste collection company. However, this waste will need to be stored within the wheelie bin for 72 hours before it can be collected. It is worth talking to your waste collection company on how to arrange this.

Some nursing or care homes may have the orange clinical or infectious waste stream. If so, this waste can be placed directly into specialist waste bins provided by your waste management company as normal. Storing for 72 hours is not required.

For care homes that don’t have an offensive (tiger stripe) or orange clinical or infectious waste stream, waste from residents with symptoms of (or who have tested positive for) COVID-19, waste from cleaning of areas where they have been (including disposable cloths and used tissues), and PPE waste from their care should be managed as follows:

• put in a plastic rubbish bag and tie when three-quarters full
• place the plastic bag in a second rubbish bag (for example, a black domestic bin liner) and tie
• put these bags in a suitable and secure place and mark for disposal 72 hours later

Waste should be stored safely and securely, for at least 72 hours, keeping it away from vulnerable individuals to whom it may cause harm. These include children and individuals who may be particularly at risk from trip hazards or suffer from confusion. It is not safe or hygienic to leave waste bags in communal areas such as communal bathrooms, toilets, corridors, stairwells or living areas. Ideally, a locked outdoor space would be best.

After the 72 hours, the waste can be put into the normal domestic waste.

Do not put any items of PPE (or face coverings of any kind) in the recycling bin.

Cleaning eye protection between uses

Cleaning and disinfecting should be done in accordance with the manufacturer’s instructions so that it does not cause the product to deteriorate and compromise its safety.

If your eye protection is reusable, you should check and follow the manufacturer’s instructions or local infection control policy on how to clean and disinfect between uses.

As a minimum, between uses you should clean with a neutral detergent wipe, allow to dry, disinfect with a 70% alcohol wipe and leave to dry; or use a single step detergent and disinfectant wipe, allowing the item to dry afterwards. You should store individually in a clean bag or lidded box to avoid possible contamination after cleaning and disinfection is complete.

Do not put eye protection on until it is completely dry. Cleaning of reusable PPE items that have been provided to you is your responsibility. Do not smoke – and avoid contact with flames while wearing eye protection.

If your eye protection is single use, it should be disposed of after use.

Aerosol generating procedures

Most care home workers are not expected to undertake aerosol generating procedures (AGPs), although some who are working in complex care may do so.

An AGP is a medical procedure that can cause the release of very small particles of COVID-19 from the respiratory tract into the immediate area and can increase the risk of respiratory transmission to those in immediate area.

AGPs which are sometimes carried out in care homes include suctioning procedures needed by a resident with a tracheostomy, residents who are receiving continuous positive airway pressure (CPAP) or ventilatory support. Oral or pharyngeal suctioning (suctioning to clear mucus or saliva from the mouth) is not classed as an AGP.

Filtering face piece class FFP3 respirators are only required when staff are undertaking AGPs. Most care workers in care homes are not generally expected to undertake AGPs and therefore do not typically need to wear FFP3 respirators. Your organisation or manager will inform you if AGPs are relevant to you and should ensure you receive the correct training to undertake the required procedure and arrange instruction if respirators or additional precautions are required. You will need a face fit test for FFP3 respirators. Please see personal protective equipment use for aerosol generating procedures for more information including use of gowns.

If you are unsure, ask you manager for clarification.

The list of procedures which are classed as AGPs in relation to COVID-19 are:

• tracheal intubation and extubation
• manual ventilation
• tracheotomy or tracheostomy procedures (insertion or removal)
• bronchoscopy
• dental procedures (using high speed devices, for example ultrasonic scalers or high speed drills
• non-invasive ventilation (NIV); bi-level positive airway pressure ventilation (BiPAP) and continuous positive airway pressure ventilation (CPAP)
• high flow nasal oxygen (HFNO)
• high frequency oscillatory ventilation (HFOV)
• induction of sputum using nebulised saline
• respiratory tract suctioning*
• upper ENT airway procedures that involve respiratory suctioning*
• upper gastro-intestinal endoscopy where open suction of the upper respiratory tract occurs*
• high speed cutting in surgery or post-mortem procedures if respiratory tract or paranasal sinuses involved

*The available evidence relating to respiratory tract suctioning is associated with ventilation. In line with a precautionary approach, open suctioning of the respiratory tract regardless of association with ventilation has been incorporated into the current (COVID-19) AGP list.

It is the consensus view of the UK IPC cell that only open suctioning beyond the oro-pharynx (middle part of the throat) is currently considered an AGP.

The evidence on respiratory tract suctioning is currently being reviewed by the AGP Panel, an independent panel set up by the 4 Chief Medical Officers to review new or further evidence for consideration.

PPE recommendations for staff performing AGPs can be found in the guidance on personal protective equipment use for aerosol generating procedures.

PPE supplies

You should inform your manager if you are concerned about shortage of PPE. Your manager will be aware about how to secure PPE and related supplies.

Acknowledgement

The development of this resource has been made possible thanks to the contribution and support of several representative organisations and individuals from across the sector.