Correspondence

Winter discharges: designated settings

Updated 13 November 2020

Applies to England

Letter to directors of adult services.

Copied to:

• local authority chief executives
• CCG CEOs
• acute trust CEOs
• directors of public health

Dear Directors and Chief Executives,

COVID-19 presents an unprecedented challenge for social care. There is an extraordinary amount of work underway up and down the country, with local authorities and care providers at the forefront of this vital response, working in partnership with the NHS. Thank you for all that you and your teams are doing to provide care and support for the many people who need it, and for helping to keep people safe during the pandemic.

The adult social care winter plan was published on 18 September, setting out our plan for the next phase of the COVID-19 response and how we will achieve this, working alongside local authorities, social care providers and the NHS. In doing all we can to protect the vulnerable from COVID-19, the plan includes a commitment to deliver a designation scheme with the Care Quality Commission (CQC) of premises for people leaving hospital who have tested positive for COVID-19 and are transferring to a care home.

This joint letter sets out:

1. an overview of the requirement for designated care settings for people discharged from hospital who have a COVID-19 positive status
2. an instruction for local authorities to commence identifying and notifying CQC of sufficient local designated accommodation and to work with CQC to assure their compliance with the infection prevention control (IPC) protocol

We have worked closely with ADASS in the development of this letter, alongside colleagues from LGA, NHSE, CQC and PHE.

What is the new requirement?

The new requirements are the following:

• Anyone with a COVID-19 positive test result being discharged into or back into a registered care home setting ^{[footnote 1]} must be discharged into appropriate designated setting ^{[footnote 2]} (ie that has the policies, procedures, equipment and training in place to maintain infection control and support the care needs of residents) and cared for there for the remainder of the required isolation period.
• These designated accommodations will need to be inspected by CQC to meet the latest CQC infection prevention control standards.
• No one will be discharged into or back into a registered care home setting with a COVID-19 test result outstanding or without having been tested within the 48 hours preceding their discharge.
• Everyone being discharged into a care home must have a reported COVID test result and this must be communicated to the care home prior to the person being discharged from hospital. The care home’s registered manager should continue to assure themselves that all its admissions or readmissions are consistent with this requirement.

The commitment builds on existing guidance on admission to care homes published on 2 April 2020 (updated 16 September) that already includes a requirement, in line with the hospital discharge service guidance, that if appropriate isolation or cohorted care is not available with a local care provider, the individual’s local authority will be required to secure alternative appropriate accommodation and care for the remainder of the required isolation period. Sufficient accommodation must be available to meet expected needs now and over the winter period. The costs of the designated facilities are expected to be met through the £588 million discharge funding.

Residents who contract COVID-19 within the care home setting should be treated and managed in line with the admission of residents in a care home during COVID-19 policy. This guidance still requires all patients discharged from hospital, even with a negative test, to be isolated safely for 14 days to ensure any developing infections are managed appropriately.

Which people will this affect?

The designation scheme is intended for people who have tested positive for COVID-19 and who are being admitted to a care home. This applies to care homes who provide accommodation for people who need personal or nursing care. This includes registered residential care and nursing homes for older people, people with dementia, and people with learning disabilities, mental health and/or other disabilities and older people.

Anyone with a COVID-19 positive test result being discharged into or back into a registered care home setting must be discharged into an appropriate designated setting ^{[footnote 3]} and cared for there for the remainder of the required isolation period.

The designation scheme does not apply to the following cohorts:

• people who have contracted COVID-19 within the care home setting – there is no requirement to transfer COVID-19 positive residents from a care home into designated accommodation, as long as safe isolation and care is being maintained
• people using emergency departments who have not been admitted to hospital do not need to be transferred into designated accommodation
• people living in their own home, including sheltered and extra care housing or living in supported living do not need to be transferred from hospital into designated accommodation

How the CQC assurance process will work

The CQC process would operate by providing assurance that each ‘designated accommodation’ has the policies, procedures, equipment and training in place to maintain infection control and support the care needs of residents. Once this assurance is received, premises would be able to receive COVID-19 positive people discharged from hospital, prior to their admission to a care home ^{[footnote 4]}.

Emphasis should be on commissioning stand-alone units or settings with separate zoned accommodation and staffing. Given the diversity of existing provision and arrangements, it is acknowledged that there needs to be flexibility to meet local circumstances. The accommodation must meet CQC registration requirements, and additionally adhere to the CQC inspection guidance in the IPC protocol.

What action is required

In time for winter, CQC has the necessary capacity and is ready to deploy to deliver 500 assurances by the end of November.

Local authorities should identify sufficient designated accommodation to meet current and future demand over winter in their local area and notify CQC of the details of these facilities as soon as possible and ideally by Friday 16. Details of this process are below. Following notification of the facilities to CQC, local authorities will be asked to work with CQC to assure their compliance with CQC’s revised Infection Prevention Control (IPC) protocol.

In order to meet this potential demand across England as quickly as possible, we aim for every local authority to have access to at least one CQC designated accommodation by the end of October. Local authorities will also be able to identify more than one facility to be CQC assured, if needed to respond to geographical spread and size, and to take into account the specific needs of particular cohorts, and increasing demands. We anticipate, for obvious reasons, that CQC will prioritise inspections in local authorities in tier 2 or tier 3. Please notify CQC as soon as a facility is available for assurance and return to CQC as and when further facilities come online. Local authorities should continue to use the existing regional structures and support systems that are in place which may be necessary to provide resilience across local boundaries.

In the longer term, CQC’s IPC protocol will be rolled into their planned programme of non-IPC focused inspections, which should increase the volume of ‘designated’ capacity even further over the coming months.

In implementing these requirements, we provide a full list of actions below.

Local authorities

Local authorities should:

• following consultation with care providers, identify a sufficient number of facilities within their local area to meet likely demand over the winter months
• working with local system leaders, ensure that the designated accommodation identified adheres to the standards set out in the CQC IPC protocol and wider requirements for registration. They should also ensure that there is repeat testing, PPE, arrangements for staff isolation or non-movement, protection from viral overload, sickness pay and clinical treatment and oversight
• notify CQC – as soon as possible and ideally by Friday 16 – by completing a proforma which includes all information required for CQC to progress to inspection, sent to ASCGovernance@cqc.org.uk. (Local authorities might choose, for expediency, to identify an initial premises, and follow up subsequently with details of further premises.) Once notified of premises selected by local authorities the CQC will inspect against the IPC protocol, report their findings and publish them on their website as part of a provider page that summarises the outcomes of inspection. Once assurance is received, premises would be able to receive COVID-19 positive people discharged from hospital, prior to their admission to a care home. CQC regulatory mechanisms, to prevent non-designated care homes from accepting COVID-19 positive people from hospital, will not apply
• communicate to clinical commissioning groups (CCGs) and providers when the new designation scheme is in place to commence its operation

CCGs and local NHS providers

CCGs and local NHS providers should:

• support local authorities to ensure that patients who receive a COVID-19 positive test result and are to be discharged to a care home, are discharged to assured accommodation ^{[footnote 5]}
• ensure that all COVID-19 test results are provided prior to discharge to enable the smooth operation of discharge, zoning, staffing and isolation, and for subsequent transfer of care. They should also ensure that patients being discharged follow the discharge to assess pathways outlined in the hospital discharge service guidance

CQC will monitor and share data regarding where these services are being commissioned across the country. DHSC, ADASS and PHE will then work together to identify any particular localities in England that require additional designated accommodation, and a prioritised roll out for CQC inspection based on local prevalence rates or population size.

What will happen next

Once local facilities have been designated and assured by CQC, Director of Adult Social Services communicate to providers and CCGs that the new designation scheme is in place. Current discharge guidance using the ‘Discharge to Assess’ (D2A), HomeFirst model, should continue to be prioritised. Current discharge arrangements, including notification of the person’s COVID-19 status to care providers and 14-day isolation of all residents discharged into care homes, should continue to apply until CCGs are notified that designated premises are available.

We are currently working with system leaders to co-design further detailed guidance, and resolve what we recognise are practical concerns. We aim to provide more detailed information to local systems shortly.

This will include further information on:

• clinical pathways for patients being discharged from hospitals to care homes
• further details on working with providers, and the operation of funding
• further details on data management
• caring for people with particular care needs, in line with line with the COVID-19 ethical principles, the relevant requirements of the Care Act 2014 and hospital discharge service guidance
• further support available to implement these new arrangements

Yours sincerely,

Tom Surrey, Director for Adult Social Care Quality, DHSC

1. Some registered residential settings might also be designated CQC assured alternative settings, where people may be discharged to designated accommodation within a registered residential setting. For example, a care home with a designated safe zone for COVID-19 positive people. ↩

2. Some people will be able to go back to their residential care home, where they are usually resident, if that care home is assured as designated accommodation. ↩

3. Some people will be able to go back to their residential care home, where they are usually resident, if that care home is assured as designated accommodation. ↩

4. This approach applies to hospital discharges only, and does not apply to admissions from people’s own homes to residential care homes. ↩

5. Some care homes may also be designated CQC assured alternative settings. ↩