Guidance

[Withdrawn] Personal protective equipment (PPE): resource for care workers delivering domiciliary care during sustained COVID-19 transmission in England

Updated 24 January 2022

This guidance was withdrawn on 4 April 2022

This guidance has been superseded by information in Infection prevention and control in adult social care: COVID-19 supplement.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 delivering care in people’s homes (domiciliary care).

Services provided by care workers include:

• ‘visiting’ or ‘hourly’ homecare (that is, where care workers visit individuals where they live)
• ‘extra care housing’ and ‘supported living’ schemes
• directly employed personal assistants
• ‘live-in’ homecare
• ‘extra care’ housing schemes

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 2021, 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 home care and management of staff and exposed patients and residents in health and social care settings.

Due to the vulnerability of residents receiving domiciliary care, there is no change to PPE advice.

What you need to know

You will need to consider how to put this guidance into practice in the context of your own circumstance. This guidance provides a minimum standard on PPE use, and employers who adopt practices that differ from those recommended/stated in the national guidance are responsible for ensuring safe systems of work, including the completion of a risk assessment approved through local governance procedures.

For the purpose of this document, the term ‘personal protective equipment’ (PPE) is used to describe products that are either approved by the Health and Safety Executive (HSE) under personal protective equipment legislation or by the Medicines and Healthcare products Regulatory Agency (MHRA) as medical devices. Both are appropriate as protective solutions in managing the COVID-19 pandemic, depending on circumstances.

Effective and appropriate use of PPE is only part of the actions to take in reducing the transmission of COVID-19. The prevention and control of COVID-19 requires the inclusion of other measures including enhanced cleaning, ventilation, keeping a safe distance and hand hygiene. This guidance should be read in conjunction with reducing risk in adult social care and provision of home care.

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
• correct technique for putting on and taking off PPE
• safe disposal of used PPE

You should 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 after the removal of PPE, equipment decontamination and waste handling. Consider carrying hand sanitiser or cleaning wipes if there may not be suitable facilities for washing your hands in a client’s home. Follow your organisation’s policies and procedures on monitoring client lists for individuals who are symptomatic or confirmed with COVID-19, permitted jewellery and hand maintenance (for example, keeping nails short, using moisturiser to keep skin on hands intact).

Determining the PPE to use

You need to take precautions to protect your own health and to prevent passing on infection to people you care for. We recommend you use PPE for certain tasks regardless of whether the person you are caring for has any symptoms of COVID-19. 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.

The PPE you will use depends upon the risk assessment taken. The risk assessment should be based on the following 2 questions:

1. Are you likely to be within 2 metres of the individual and carrying out direct personal care or domestic duties?
2. Are you more than 2 metres from a client, undertaking domestic duties and not delivering personal care?

While risk assessment is an organisational responsibility, you should be involved as you see people you care for and will notice any change in their condition. A dynamic risk assessment will determine when and for which clients or duties items such as eye protection and Type IIR masks should be worn, for example when providing personal care for clients who are known to have respiratory symptoms or a known positive coronavirus test result within 10 days (14 days if medically advised). The risk assessment should also include whether the client is displaying early symptoms of COVID-19 and what actions in terms of PPE carers should take if they think this is the case. This needs to be carefully considered in each interaction.

The same principles apply whether you are providing care within the client’s home or supporting them outside the home (for example, a visit to a family member, a walk in the park or a visit to the shops or a cafe). Before an outing with your client, consider if your activities include provision of direct personal care (for example, assisting the supported individual with toileting) and take the appropriate PPE with you as outlined in the section within 2 metres and carrying out direct personal care or domestic duties. Occasional physical support (for example, helping out of a chair) or assistance with everyday tasks (for example, shopping) do not require gloves and aprons. There is no longer a legal requirement to wear face coverings in indoor settings or on public transport. However, the government expects and recommends that people continue to wear face coverings in indoor areas where they may come into contact with people they do not normally meet, particularly in crowded, enclosed or poorly ventilated spaces. People receiving support in domiciliary settings are likely to be more vulnerable and to experience worse outcomes in relation to the virus than the general population so it is particularly important that this is reflected in the approach of staff who provide support to them. Type I or II surgical masks (or Type IIR mask if your employer has good supply) are sufficient.

You should discuss situations which you are unsure about 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 raising a concern 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.

Where people may have difficulty wearing masks as required by this guidance, this should be discussed between you and your employer. 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.

There may be circumstances where following this guidance presents challenges in caring for the client, for example, where lip-reading or facial recognition is especially important for care. Your organisation will decide how best to put into practice PPE guidance to minimise any negative impact on clients, while maintaining your health and safety. An understanding of the client’s needs will form part of the risk assessment and should be undertaken in these circumstances.

Supported individuals who are clinically extremely vulnerable

Clients who are clinically extremely vulnerable or at higher risk from COVID-19 may need additional precautions, for example avoiding contaminating surfaces that might be touched by the client. If you have any concerns about whether your clients should belong to this group, then you should discuss this with your manager.

When delivering care to a client who is clinically extremely vulnerable, please follow the sections on within 2 metres and carrying out direct personal care or domestic duties and more than 2 metres from a client and carrying out domestic duties. The primary purpose of wearing PPE in this scenario is to protect the vulnerable individual.

See guidance on shielding and protecting people who are clinically extremely vulnerable from COVID-19.

Supported individuals with learning disabilities, mental health problems, autism and dementia

There may be challenges in following PPE recommendations and 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 client or others.

A comprehensive risk assessment should be undertaken for each client identifying the specific risks for them. It is important that in doing this you do not alter the PPE items in any way as this could reduce their effectiveness in protecting staff or the people you are providing care for.

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

Supported individuals who have previously tested positive for COVID-19 or have been vaccinated

The COVID-19 vaccination programme has been rolled out across the country with the most high-risk groups being prioritised. This included those in receipt of domiciliary care and care workers delivering care in people’s homes. Vaccination will help 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.

Within 2 metres and carrying out direct personal care or domestic duties

Table 1: Within 2 metres of the client and carrying out direct personal care or domestic duties

Disposable gloves (vinyl or nitrile)	Yes
Disposable plastic apron	Yes
Fluid-repellent surgical mask (Type IIR)	Yes
Eye protection (where there is a risk of contact with body fluids)	Yes

These recommendations apply:

• whenever you are within 2 metres of anyone (including the client or household members) irrespective of whether they have COVID-19 symptoms or have tested positive
• to all direct personal care, for example, assistance to use the toilet, changing dressings, and when unintended contact with clients is likely (for example, when caring for clients with challenging behaviour)
• whatever your role in providing care (these recommendations therefore apply to all staff including care workers, managers and supervisors and cleaners, for example)
• regarding eye protection, when you have risk assessed there is a risk of splashing of body fluids (including respiratory secretions) into the eyes

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

Disposable gloves

Disposable gloves are single use. When worn correctly, single-use gloves protect you from contact with the client’s body fluids and secretions. Single use means gloves should be changed between every contact with another person and while working with the same client (for example after helping with using the bathroom). They should also be changed after using gloves for other activities, for example cleaning.

You should dispose of them immediately after completion of a procedure or task and after each person being cared for, and then wash your hands. You should take care not to touch your face, mouth or eyes when you are wearing gloves.

Disposable gloves may be worn for routine cleaning, however if chemicals are being used as part of a decontamination schedule a COSHH assessment should be carried out and the correct PPE worn.

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.

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 requires 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, then wash your hands thoroughly making sure they are completely dry before putting on new gloves.

Your provider needs to consider the type of different gloves available for the duties you are doing. This includes the gloves required in relation to cleaning products; follow the manufacturers’ instructions.

Disposable plastic aprons

Disposable plastic aprons are required. They are for single-use only and are worn to protect your clothing from contamination when providing direct care or if there is a risk of splashing.

You should wear disposable plastic aprons when providing personal care and when exposure to body fluids is likely. Disposable plastic aprons are single use and you should dispose of them immediately after completion of a procedure or task and after each client, and then wash your hands.

Fluid-repellent (Type IIR) surgical mask

A fluid-repellent surgical mask (FRSM) is required. Fluid repellent surgical masks are Type IIR surgical masks and provide additional protection from respiratory droplets produced by clients (for example, when they cough or sneeze). Wearing a Type IIR surgical mask also protects clients by minimising the risk of you infecting them via secretions or droplets from your mouth, nose and lungs.

A fluid-repellent surgical mask is single use and should be disposed of at the end of each homecare visit and a new fluid-repellent surgical mask applied when entering a different client’s house.

You should also remove and dispose of the mask if it becomes damaged, visibly soiled, damp, or uncomfortable to wear.

You should ensure that you have enough masks for the duration of your shift.

You should not touch your face mask unless it is to put on or remove it. Make sure the mask fits as snugly to the face as possible, this may include the need to adjust the face straps or ear loops. They should not be crossed over as this increases the gap on the cheeks. Consider trying a different mask if the fit is poor.

The mask is worn to protect you and to help to prevent you transmitting virus particles to others.

Eye protection

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 client with respiratory symptoms), and from splashing of secretions (for example, of body fluids or respiratory excretions). Eye protection should cover the eye or face completely so prescription spectacles are not sufficient. It should be used in conjunction with a fluid-repellent surgical mask and 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 googles as well.

If you are provided with goggles or a visor that is reusable, you should be given instructions on how to clean and disinfect and store them following the manufacturer’s instructions or local infection control policy.

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 in a bag or lidded box to avoid possible contamination after cleaning and disinfection is complete. If you are wearing both prescription glasses and goggles, both will need to be cleaned. For prescription glasses or spectacles, use the cleaning fluid or wipes that are normally used for spectacles as disinfectant may damage the coatings on the lenses.

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 eye protection is labelled as for single-use, it should be used for a single task, then it should be disposed of into the client’s domestic waste stream. Please see section on what to do with waste including PPE from a COVID-19 positive client.

More than 2 metres from a client and carrying out domestic duties

Table 2: When more than 2 metres from a client undertaking domestic duties and not delivering personal care

Disposable gloves (vinyl or nitrile)	Yes
Disposable plastic apron (unless there is a risk of contact with bodily fluids or secretions or splashing onto your clothing)	No
Type I or II surgical mask or Type IIR	Yes
Eye protection (unless the client has had a positive COVID-19 test and is quarantining, or has respiratory symptoms)	No

These recommendations apply:

• where there is no personal care being given, but domestic tasks are being undertaken such as removing medicines from their packaging, prompting people to take their medicines, preparing food for clients who can feed themselves without assistance or cleaning
• to all staff including care workers, managers and supervisors and cleaners

If it is not possible to maintain 2 metres away from anyone in the household who has respiratory symptoms (including the client), follow the recommendations in the section within 2 metres and carrying out direct personal care or domestic duties.

If you undertake cleaning duties, then you should use normal household products, such as washing with detergent and hot water followed by disinfecting with bleach, as these will be very effective at getting rid of the virus on surfaces. Frequently touched surfaces should be cleaned 2 or 3 times a day. If you are cleaning within 2 metres of a client, then you should wear a Type IIR mask, plus the gloves and aprons you normally use for cleaning.

Disposable gloves

Disposable gloves are required as per standard infection prevention and control precautions (for example, contact with clients’ bodily fluids or chemical hazards or if anyone in the household is shielding). Single use means gloves should be changed between every contact with another person and in-between tasks. Hands should be washed and dried, or if handwashing facilities are not available hands can be sanitised using hand sanitiser prior to putting on another pair of gloves.

Vinyl gloves provide sufficient protection for the majority of duties in the care environment, providing the correct size of glove is chosen according to the wearer’s hand size.

If there is a risk of gloves tearing, or the task requires a high level of dexterity, or requires 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, then hand hygiene is needed after removal of the original gloves. Hands should be thoroughly dried to make the donning of new gloves easier and reducing the risk of gloves tearing before donning a clean pair.

Your provider needs to consider the types of gloves available for the duties you are doing. This includes the gloves required in relation to cleaning products.

Disposable plastic apron

Disposable aprons are only required where there is a risk of contact with bodily fluids or secretions, or splashing onto your clothing.

Type I or II surgical mask

Type I or II masks are sufficient for domestic duties. However, if your employer already has a supply of fluid-repellent (Type IIR) surgical masks, these are acceptable. You may also use a Type IIR if you have risk assessed that you may be carrying out domestic duties in a room where there is the supported individual is COVID-19 positive or symptomatic.

The facemask should be single use and disposed of before leaving the client’s home. A new mask should be donned before entering the next client’s home.

You should also remove and dispose of the mask if it becomes damaged, visibly soiled, damp, or uncomfortable to wear and do not touch your face mask unless it is to put it on or remove it. The maximum period of time for wearing a Type I or II mask is 4 hours.

You should ensure that you have enough masks for the duration of your shift.

Eye protection

Risk assess the need for eye protection. Eye protection is not required for infection prevention reasons unless you know that the client has had a positive COVID-19 test and is self-isolating, or has respiratory symptoms. Ensure the eye protection is used as a disposable item of PPE or as a reusable item in line with the manufacturers’ guidance. Eye protection may be indicated if there is a risk of splash hazard from the cleaning products.

Care workers undertaking ‘live-in’ care

All care workers who live in the household of the people they are supporting should take part in the weekly testing service for homecare workers. It is essential that all homecare staff are tested regularly to reduce the risk of transmission across different settings and to help keep clients and staff safe. See A testing service for homecare workers in England for more information.

As outlined in Determining which PPE to use, you and your employer will need to do a risk assessment to determine which PPE to use and this may include your client. This risk assessment may include wearing of Type I or II masks for source control (that is, the mask is worn to protect others from you).

If you are a care worker who is living with the supported individual for a long period of time, you are considered part of the household and you do not need to wear PPE when doing domestic duties, unless the person you support, or a member of their household, tests positive for COVID-19, or develops respiratory symptoms such as coughing or sneezing. It remains important, however, that you continue to use the PPE needed for the care you provide. For example, gloves and an apron should be worn if you are handling soiled linen, or may come into contact with body fluids such as urine, faeces or blood.

If the individual you are supporting develops respiratory symptoms, tests positive for COVID-19, or is self-isolating, you should follow the recommendations in the following sections, according to the work you are doing:

• within 2 metres and carrying out direct personal care or domestic duties and
• more than 2 metres from a client and carrying out domestic duties

If someone in the household develops symptoms of COVID-19, or has tested positive, you should also follow the Stay at Home guidance.

If you arrive in England to deliver ‘live-in’ homecare from outside the UK, you and your employer should refer to the current guidance on travel and quarantine arrangements.

Using PPE

Putting on and removing PPE

You need to put on and take off your PPE at least 2 metres away from the person you are visiting and anyone in the household with a cough. For more information, see the video on putting on and removing PPE.

You need to put a face mask on before you enter or immediately as you enter a client’s home or your work base. Your organisation will need to work out how best to do this in your work base. If you need to remove your face mask for whatever reason, ensure you do this 2 metres away from others (including clients, household members and other staff) and replace with a new face mask as soon as practical.

What to do with waste including PPE

Waste should be placed in a refuse bag and can be disposed of as normal domestic waste unless the client has confirmed COVID-19 or symptoms of COVID-19, that is, a new continuous cough, a high temperature, a loss of, or change in, your normal sense of taste or smell.

Waste from people with symptoms or confirmed COVID-19, waste from cleaning of areas where they have been (including disposable cloths and used tissues) and PPE waste from their care:

1. Should be put in a plastic rubbish bag and tied when three-quarters full.
2. The waste can be disposed of in the domestic waste stream 72 hours later.

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

Cleaning eye protection (goggles and visors) between uses

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 or disinfectant wipe, allowing the item to dry afterwards. You should store in a 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.

Cleaning your uniform or work clothes

Regardless of wearing PPE, uniforms should be laundered:

• separately from other household items
• at the maximum temperature the fabric can tolerate, then tumble dried and/or ironed

If you do not wear a uniform, you should change your clothing immediately when you get home and launder clothing used for work as described for uniforms above. This does not need to apply to underclothes unless there was contamination from the client’s body fluid (for example, vomit, or fluids have soaked through external clothing). If you wear prescription glasses or spectacles, clean them using the cleaning fluid or wipes that are normally used for spectacles.

Shortage of PPE

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

Aerosol generating procedures

Most homecare workers are not expected to undertake aerosol generating procedures (AGPs), although some who are working in complex care may do so. Your organisation or manager will inform you if AGPs are relevant to you and will instruct you if FFP3 and/or additional precautions are required.

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 the community setting include suctioning procedures with a client with a tracheostomy, clients who are receiving continuous positive airway pressure (CPAP) or ventilatory support.

Oral/pharyngeal suctioning (suctioning to clear mucus / saliva from the mouth) is not classed as an AGP. 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.

Filtering face piece class 3 (FFP3) respirators are only required when staff are undertaking AGPs.

If you are unsure ask your 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/high speed drills and 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/post-mortem procedures if respiratory tract/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 is currently considered an AGP for example, oral/pharyngeal suctioning is not an AGP. The evidence on respiratory tract suctioning is currently being reviewed by the AGP Panel which is an independent panel set up by the 4 CMO’s to review new or further evidence for consideration.

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

Your organisation or manager will inform you if AGPs are relevant to you and instruct you on additional precautions required. Further information on AGPs including PPE recommendations for staff performing AGPs can be found in guidance on infection prevention and control (IPC) and personal protective equipment use for aerosol generating procedures.

Acknowledgement

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