Guidance

[Withdrawn] Discharge into care homes: designated settings

Updated 11 February 2022

This guidance was withdrawn on 1 April 2022

The information in this guidance has been superseded by Infection prevention and control in adult social care: COVID-19 supplement.

Applies to England

1. Introduction

This guidance has been produced with NHS England (NHSE), UK Health Security Agency (UKHSA) and the Care Quality Commission (CQC), in consultation with the Local Government Association (LGA), Association of Directors of Adult Social Services (ADASS), care provider associations and user groups.

This guidance should be read in conjunction with the guidance on admission to care homes and the hospital discharge and community support: policy and operating model.

2. Purpose of the guidance

This guidance sets out:

• the discharge arrangements for people who have tested positive for coronavirus (COVID-19)
• the requirements designated setting providers must meet
• key information to assist local authorities in planning to ensure they have enough designated accommodation
• CQC’s infection prevention control (IPC) protocol

This guidance should only be used for individuals who need care in a residential or nursing home and have tested positive for COVID-19 within 48 hours prior to being discharged from a stay in hospital. The ‘home first’ approach should continue to be followed as the preferred option.

3. Who this guidance is for

This guidance is intended to be used by:

• clinical, ward and hospital discharge teams
• registered providers
• care home staff
• local authorities
• commissioners

This guidance applies to providers who are registered with CQC for the regulated activity of accommodation for people who require nursing or personal care. This includes providers of residential care and nursing homes for older people, people with dementia, people with learning and/or other disabilities and people with mental health conditions.

4. What a designated setting is

To further support safe and timely discharge and protect care home residents and staff from COVID-19, the Department of Health and Social Care (DHSC) have worked with the CQC to develop a designation scheme to identify specific care homes that will act as designated settings.

This scheme ensures that anyone who has tested positive^{[footnote 1]} and is still likely to be infectious with COVID-19 is discharged to a designated care setting to complete a period of isolation before moving to a care home. These settings will meet a set of agreed standards to provide safe care for COVID-19 positive individuals.

Designated settings are one element of the government’s wider efforts to minimise the risks of spread and transmission of COVID-19.

5. Who designated settings are for

Designated settings are intended for individuals who are leaving hospital and require care within a care home for the first time, or are returning to their normal care home, and are likely to be infectious with COVID-19 and/or are within an appropriate formal isolation period having tested positive for COVID-19. For those entering care homes, please refer to the guidance on admission to care homes for information on appropriate formal isolation periods.

There may be exemptions for particular individuals on clinical or care grounds; further information is set out below.

6. Discharge arrangements for people who need a residential or nursing home

Every person must receive a COVID-19 PCR test result within 48 hours before discharge from hospital – except for those who are known to have previously tested positive for COVID-19 and are within 90 days of their symptom onset or positive test date (if asymptomatic) and have no new COVID-19 symptoms or exposure or recent travel outside the UK.

Individuals who receive a negative test result within 48 hours before discharge from hospital, should be discharged to a care home in line with requirements set out in the admission and care of residents in care homes guidance.

Individuals who receive a positive test result within 48 hours before discharge, or are exempt from testing, should undergo a clinical assessment to determine their onward movement and isolation requirements.

See the steps below which describe an individual’s onwards movement following discharge from hospital.

Step 1

A person requires a residential or nursing home and has received a positive PCR test for COVID-19 and is within a period of 90 days from their initial illness onset or positive test date. The individual must no longer meet the criteria to reside in an acute hospital setting, and have no underlying severe immunosuppression.

Step 2

The hospital clinical team, in conjunction with an infection specialist if required, undertake a clinical assessment against the following 2 questions:

Question 1

Has the individual completed their isolation period from their symptom onset or positive test result (if asymptomatic)?

Isolation can only be stopped when clinical improvement criteria (in section 2 of ‘Stepdown of infection control precautions and discharging COVID-19 patients and asymptomatic SARS-CoV-2 infected patients’) are met for the following:

• clinical improvement with at least some respiratory recovery
• absence of fever (less than 37.8°C) for 48 hours without the use of medication
• no underlying severe immunosuppression

Question 2

Is the individual free from any new COVID-19 symptoms?

New COVID-19 symptoms include a new continuous cough, high temperature and/or loss of, or change to, the individual’s sense of smell or taste. Older people and people with a learning disability or autism may not present with ‘typical’ symptoms. A post-viral cough and/or loss of, or change to, normal sense of smell or taste is known to persist for several weeks in some cases and would therefore not be considered new symptoms.

If the answer to one or both questions is ‘no’:

• the individual may pose an infection risk so should be discharged to a suitable designated setting to complete their isolation period

If the answer to both questions is ‘yes’:

• the individual may be discharged to any care home in line with the requirements set out in guidance on admission and care of residents in care home during COVID-19

Action for NHS Providers

NHS Providers organisations must ensure that every person being discharged into a care home (including designated settings) receives a COVID-19 PCR test result 48 hours prior to discharge. The test result should be shared with:

• the individual
• their key relatives or advocates
• the relevant care home provider in advance of discharge taking place

The clinical assessment, as per the steps outlined in this guidance, should be undertaken by the hospital clinical team led by a responsible consultant. The hospital clinical team should provide detailed information about the clinical assessment in the discharge summary information, which should also include the individual’s COVID-19 test result and information about their specific needs. Any member of the hospital clinical, ward or discharge team can communicate this information to the care home (including designated settings).

Crucial to achieving a successful discharge outcome is early discharge planning involving conversations between hospital and care home staff, as well as the person, their family or advocates, ensuring a consistent focus on the principles of personalised care.

The hospital (clinical, ward or discharge team staff) should ensure the designated settings pathway is clearly explained to the individual (and where appropriate, family or advocates) including why it is important for everyone’s safety that they go to a designated setting if they are likely to be infectious with COVID-19. The decision to accept or decline an admission lies with a registered manager of the care service. Care home managers should be given sufficient time to take decisions. Further information is provided in section 11, ‘Support planning’ below.

7. COVID-19 management in designated settings

Self-isolation period

Individuals should isolate for 10 days following a positive test result.

Individuals who are able to take lateral flow tests should take a lateral flow test from day 5.

If 2 consecutive negative lateral flow tests are received 24 hours apart, the individual can end self-isolation before 10 days.

Consideration should also be given to the following factors when ending isolation before day 10:

• clinical improvement with at least some respiratory recovery

• absence of fever (less than 37.8°C) for 48 hours without the use of medication

• no underlying severe immunosuppression

The total isolation period can be shared across the hospital and designated setting. This applies to individuals with repeat positive tests within the 90-day window – see the section on retesting below, under ‘What to do if someone develops new COVID-19 symptoms during their isolation period’.

For information on what happens when an individual completes their isolation period, see the section below on ‘Stopping isolation and allowing transfer from a designated setting to a care home’.

Also see guidance on admission to care homes.

What to do if someone becomes a contact during their self-isolation period

Individuals should self-isolate for 10 days if they test positive for COVID-19. In addition, they should complete any further period of isolation resulting from being a contact.

This additional period should be completed in the care home as designated settings are not intended for the isolation of contacts. For more information on contacts, see the COVID-19: management of staff and exposed patients or residents in health and social care settings guidance and the guidance on admission to care homes.

The individual should not be retested by PCR within 90 days from their initial illness onset or test date (if asymptomatic), unless they:

• develop any new symptoms of COVID-19
• need to take a PCR test upon entry into the UK

What to do if someone develops new COVID-19 symptoms during their isolation period

If the individual developed new COVID-19 symptoms during their isolation period, they should be retested using a PCR and clinically assessed to determine next steps.

For more information, see COVID-19: management of staff and exposed patients or residents in health and social care settings.

Stopping isolation and allowing transfer from a designated setting to a care home

After the self-isolation period in a designated setting is completed, the individual must have a clinical assessment in line with the clinical improvement criteria. If the criteria are met, the individual can then be moved to a care home without the need for a further COVID-19 test or isolation.

8. Locating a designated setting

When designated settings were introduced in November 2020, local systems worked quickly and collaboratively to ensure sufficient settings were identified and designated to meet expected demand across England. All local authorities must ensure they have sufficient designated settings capacity to meet expected demand for winter 2021 to 2022. This may be a shared setting with another local authority (so long as they are confident, they can meet local demand for the service).

Local authorities can 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 people and increasing demands.

The costs of designated settings will be met through the additional £478 million funding package to continue the hospital discharge programme until 31 March 2022.

Local partners will already be working together to ensure sufficient accommodation is available to meet expected demand over the winter period. For arrangements organised from the date of this guidance, the Clinical Commissioning Group (CCG) should also seek approval for the affordability of this from the NHS regional lead identified as the lead for the hospital discharge programme.

The CQC process will provide assurance that each designated setting has the policies, procedures, equipment, staffing levels, appropriate skills mix and training in place to maintain IPC and support the care needs of residents. Designated settings are also expected to have appropriate physical separation of COVID-19 positive people, and a dedicated staff team. For details of the full IPC measures in designated settings, see CQC’s IPC protocol.

Where designated settings need to be redesignated, local authorities should seek the advice of CQC in the first instance to determine whether the home will need to be re-inspected before being switched on again as a designated setting.

Once this assurance is received, settings will be able to receive people who are infectious with COVID-19 discharged from hospital.

How a setting is designated

Local systems should adopt a flexible approach about how to deliver designated settings to ensure that there are enough settings in place to meet local needs. These designated facilities will be best identified locally and can include care homes, NHS community hospitals or other bedded or residential facilities.

All types of designated facilities must be specifically assessed and assured by CQC to receive people who are infectious with COVID-19, unless they are NHS facilities, where local arrangements provide that assurance.

Each designated setting:

• must meet CQC registration requirements and not be in breach of any regulations
• must meet the CQC IPC protocol
• should have an existing rating of ‘good’ or ‘outstanding’ – if the service is rated as ‘requires improvement’ with no breach of regulation, CQC will assess this on a case-by-case basis
• must be able to demonstrate appropriate physical separation of COVID-19 positive people
• must have a dedicated staff team

Care home providers must also ensure they have sufficient insurance cover to provide the services and we advise that care homes intending to become a designated setting have a conversation with their insurers at an early stage to discuss the implications. The Designated Settings Indemnity Support (DSIS) is available to care homes assured by CQC as designated settings, or intending to be assured by CQC, and which are not able to obtain sufficient insurance.

Local systems – CCGs, local authorities and NHS trusts – should work through agreed Integrated Care System (ICS) governance and decision making arrangements to discuss and agree local needs for designated settings capacity and indemnity ahead of making an application for DSIS. See the frequently asked questions about the Designated Settings Indemnity Support on the NHS Resolution website.

CQC regulations set out what is required of providers with regards to their financial viability. Insurance arrangements will necessarily feature in any assessment of this. If an individual provider is concerned their insurance arrangements may put their financial viability at risk and breach the CQC regulations, then they should inform the CQC.

9. Advice for local authorities

Decisions should continue to be made at a local level about how best to deliver designated settings, including where such settings are shared with neighbouring authorities, or in partnership with the NHS.

Local authorities, in partnership with the care provider, should notify CQC by completing a proforma on any proposed designated settings for CQC to inspect. This should be sent to ascgovernance@cqc.org.uk.

Once notified of premises selected by the local authority, CQC will inspect against their IPC protocol. CQC will report on their findings and publish a summary of the outcomes alongside details of the care home displayed on the CQC website.

Some local authorities may agree with local NHS partners to make use of NHS settings to fulfil the role of a designated setting. In this instance, it will not be necessary for the NHS setting to be inspected by CQC against the IPC protocol specifically for the purpose of this arrangement. This is because NHSE will conduct their own assurance and checking of these facilities.

Local authorities should communicate to CCGs and providers when settings are ‘switched on’ to receive patients who are infectious with COVID-19 leaving hospital. Local authorities must also ensure that designated beds are operational as soon as possible after CQC assurance and contractual arrangements are in place.

Local authorities, in partnership with the care provider, can, at any time, put forward additional settings for CQC to inspect or propose the removal of designation. If a designated setting is stepped down, local authorities should ensure they communicate this clearly to CQC (see section 14 for further information).

Managing designated setting capacity

Local authorities must ensure that sufficient settings are available to meet expected needs now and over the winter period. This is vital to minimise transmission of COVID-19 and protect the lives of those living and working in care homes.

Local authorities should undertake a risk assessment when sourcing additional capacity to ensure that the needs of the individuals are met while also ensuring COVID-19 transmission is minimised.

The individual risk assessments should take into account:

• the individual’s personalised care needs
• the individual’s care and support plan, including any Advance Care Plan
• the precautions that will be taken to prevent infection (including PPE use, ventilation and hand washing)
• the layout of the setting including whether the individual’s room has ensuite bathroom facilities
• the potential risks to other care home residents
• whether the setting is willing to receive the individual

This risk assessment should be guided by the CQC process to provide assurance that each designated setting has the policies, procedures, equipment, staffing levels, appropriate skills mix, and training in place to maintain infection prevention control and further support the care needs of residents.

In exceptional circumstances, where designated setting capacity becomes temporarily full in a local area, local authorities should seek to expand capacity as soon as possible. This should be through additional designated settings or using existing regional structures and support systems to share capacity across local boundaries.

Local authorities should ensure that any temporary arrangements (such as local community hospital beds and extra care settings) are communicated clearly to local providers and CCGs. Local systems should follow a business as usual approach to manage local demand and to be aware of any changes to the systems across different regions.

10. Exemption on clinical or care grounds

All hospitalised care home residents who tested positive for COVID-19 and are likely still to be infectious with COVID-19 should be discharged into a designated setting.

However, in exceptional circumstances, there may be instances where discharge to a designated setting may not be appropriate. This may apply to people with mental health issues, learning disabilities, autism or dementia whose needs require a specialist care home service as well as people at the end of their lives or those in drug and alcohol settings whose needs cannot be met in the designated settings.

This decision should be made following a risk assessment undertaken by an appropriate health and social care practitioner.

This risk assessment should consider:

• the individual’s personalised care needs
• the individual’s care and support plan, including any Advance Care Plan
• the precautions that will be taken to prevent infection (including PPE use, ventilation and hand washing)
• the layout of the setting including whether the individual’s room has ensuite bathroom facilities
• the potential risks to other care home residents
• whether the individual is at the end of life
• whether the setting is willing to receive the individual

There may be exceptional circumstances where the assessment concludes that it is not appropriate for the individual to be discharged to a designated setting. If this happens, the local authority should make alternative arrangements in line with their personalised care support plan. These alternative arrangements should always be risk assessed in accordance with the above framework, to ensure that the individual is able to receive care that is appropriate for their individual care needs while the setting is able to effectively manage the potential risk of transmission to other residents and staff. The individual should not be expected to remain in hospital for their isolation period.

Refer to SCIE guidance and the admissions to care homes guidance for further support on supporting people with dementia in care homes. You can also refer to legal guidance for mental health, learning disability and autism, and specialised commissioning services supporting people of all ages during the coronavirus pandemic.

11. Support planning

People should expect to receive high quality care from acute and community hospitals. This includes regular and open sharing of information on the next steps for an individual’s care and treatment, as well as clarity on plans and joint decision-making processes for discharge into designated settings.

The designated settings pathway should be clearly explained to the individual (and where appropriate, family or advocates) prior to discharge, and the individual must be involved in the decision-making process, by actively seeking their views.

It may be helpful to reference information on personalised care and support, in particular staying in control: when things need to change. The conversation should cover the following points:

• the reasons that designated settings were established. They were established to provide the safest and most appropriate care and support for people leaving hospital to care homes (and for the other residents of respective homes), who are likely to be infectious with COVID-19
• information regarding location, set up and facilities of the designated setting, including how it will meet the specific needs of the individual being discharged
• the process for assessment, reablement and support planning for care (if required) following an individual’s stay in a designated setting, including information on how any onward transfer to their usual or permanent place of residence might be handled
• a person-centred multi-agency meeting should be convened (virtually if necessary), to discuss;
  • the prognosis from the positive test
  • how this may impact an individual with a learning disability, autism or living with dementia, for whom discharge to a designated setting is being considered

This should ensure that the potential challenge of multiple moves for the individual has been considered, and conversely the impact and potential negative consequences of remaining in hospital. This will ensure that appropriate consideration is given to the need for reasonable adjustments, to enable the best outcome for the individual.

It is the responsibility of CCGs and local authorities to ensure individuals are discharged into an appropriate setting that meets their care needs. Current government guidance on isolation states that individuals tested as COVID-19 positive must complete a formal isolation period prior to moving to a non-designated care home. For those entering care homes, formal isolation periods are set out in the guidance on admission to care homes. This guidance is based on balancing the individual’s care needs with the need to protect care homes from COVID-19 transmission.

If, following these conversations, an individual does not wish to be discharged to a designated setting, then alternative care arrangements should be discussed. An individual risk assessment should be undertaken to determine that the alternative non-designated care home is able to safely care for them (bearing in mind their positive COVID status) and meet their needs.

The individual risk assessments should take into account:

• the individual’s personalised care needs
• the individual’s care and support plan, including any Advance Care Plan
• the precautions that will be taken to prevent infection (including PPE use, ventilation and hand washing) 
• the layout of the setting including whether the individuals room has ensuite bathroom facilities
• the potential risks to other care home residents
• whether the setting is willing to receive the individual

The decision makers should consider the ethical framework for adult social care, alongside issues of consent to determine a course of action that is in the best interests of the person. The Mental Capacity Act 2005 should be followed if the person being discharged is unable to understand information about the discharge arrangements or the requirements of the isolation period. 

Reasonable adjustments should be considered and accommodated to ensure that disabled people are able to be supported safely and appropriately within designated settings. It is important to engage with both the person themselves and with their families or personal assistants, who will be clear about their needs if a move to a designated setting is under discussion. This may require the support and advice of community social care and community health professional teams. CCGs and local authorities should ensure this is available. Refer to the NHS guidance on management of patients with a learning disability, autism or both. The rights of all affected people should be considered under the Human Rights Act.

12. Clinical support

Where a designated setting is an NHS facility it will have access to clinical support from the NHS.

Where a designated setting is a care home, it will be able to access the primary and community health services support offer available to all CQC registered care homes (Enhanced Health in Care Homes). See the guidance on admission to care homes for further details.

Enhanced Health in Care Homes (EHCH) supports the NHS Long Term Plan goal of ‘dissolving the historic divide’ between primary care and community healthcare services, and sets a minimum standard for NHS support to people living in care homes. Requirements for the delivery of EHCH by Primary Care Networks (PCNs) are included in the Network Contract Directed Enhanced Service (DES) for 2021/22.

Complementary EHCH requirements for relevant providers of community physical and mental health services have been included in the NHS Standard Contract. The following should all be in place:

• every care home has a named clinical lead
• every care home is aligned to a named PCN
• every care home has a weekly care home round, with input from the multi-disciplinary team (MDT). The MDT will usually be comprised of primary care, community services, and social care staff and can include support from the community mental health team (CMHT), and the voluntary, community and social enterprise (VCSE) sector
• for every resident, the MDT must aim to carry out an assessment of need within 7 working days, unless there is a good reason for a different timescale. This will include assessment of the physical, psychological, functional, social and environmental needs of the person, including end of life care needs where appropriate;
• the MDT must aim to develop a personalised care and support plan for new residents based on the assessment of need, within 7 working days unless there is good reason for a different time scale
• the rollout of structured medication reviews to those in care homes identified as a clinical priority

A summary of the primary and community support offer to people in care homes can be found in the admissions and care of residents in a care homes guidance. The information in this section should be read alongside this guidance and alongside the enhanced health in care homes framework. Designated settings for supporting COVID-19 positive people will vary between health and social care systems. For those areas using care homes for this purpose, there should be a review of the NHS clinical support and equipment being provided into these homes.

CCGs are responsible for ensuring the necessary clinical support is in place. This should build on existing support and structures, for example those established through the EHCH service, considering whether any specific additional services are necessary to meet the needs of COVID-19 positive patients and recognising that additional support may be needed given the cohort of people being cared for. The clinical support should be locally agreed between local acute, community health and primary care providers and the providers of the designated settings.

Additionally, CCGs are responsible for ensuring the necessary clinical support is in place for clinical assessments in designated settings.

If a care home is concerned about the additional clinical support provided to them for COVID-19 positive patients, they should raise this with their CCG. Concerns about routine care delivered through EHCH should be raised with their PCN clinical lead in the first instance. 


Caring for people in a designated setting

People discharged from hospital to a designated setting on the discharge to assess arrangements pathway 2 should be supported to engage in short-term therapy if it has been determined that they need it to aid their recovery and maximise their independence.  This could include the provision of a paper copy of an exercise programme by the acute or community hospital with exercises for both upper and lower limbs. It is important to ensure individuals in designated settings are supported to regain and maintain their function during their isolation period.

13. Visiting

Visiting a COVID-19 positive individual in a designated setting may present a high risk of transmitting infection – both to the visitor and to the community. Highly transmissible variants can defeat rigorous IPC measures.

While vaccination is proving very effective, we are still seeing some cases of severe illness, hospitalisation and death of people who have been vaccinated. Therefore, visitors (including essential care givers) should only visit residents who infectious with COVID-19 in designated settings in exceptional circumstances (for example, severe distress or end of life). Visitors should follow the principles outlined in the visiting guidance.

14. Information collection

Local authorities should notify CQC of all settings that they nominate to be designated to receive COVID-19 positive individuals. This includes notifying CQC of NHS facilities that will not require CQC assurance; where they intend to share settings with another local authority; or where they are making alternative arrangements, such as supporting individuals to temporarily return to friends, family, or shared lives with home care support.

Local authorities must also notify CQC (by emailing ascgovernance@cqc.org.uk) when they decommission a designated setting so that NHS partners are provided with up to date information. Ordinarily, it will take up to 2 weeks before the decommissioned designated setting is no longer visible in the Capacity Tracker.

Providers of designated settings are asked to input data into the Capacity Tracker on a daily basis in line with the admission and care of residents in care homes guidance. This will comprise information on the number of beds in the designated setting that are currently occupied, and the number that are currently available for admissions.

This will support partners to understand how well we are able to meet potential demand.

For more information see CQC guidance on designated settings.

1. Individuals that cannot undergo testing are assumed to be potentially infectious as their COVID-19 status is unknown. As a precaution, they should self-isolate for 10 days in the care home as a precaution. Designated settings are only for those who test positive for COVID-19. ↩