Guidance

Infection prevention and control (IPC) in adult social care: acute respiratory infection (ARI)

Updated 28 March 2024

Applies to England

What has changed

This guidance has been updated in line with changes to testing policy from 1 April 2024.

Routine COVID-19 lateral flow device (LFD) testing of asymptomatic individuals prior to discharge from hospital into care homes is no longer required. Testing may still be undertaken, based on local risk assessment by the hospital together with the care home, for example during outbreaks.

The ordering portal for accessing LFD test kits for outbreak testing has now closed. During a suspected outbreak of acute respiratory infection (ARI), settings can access multiplex polymerase chain reaction (PCR) tests through their local health protection team (HPT) to help identify the infection responsible.

Guidance on visiting has been updated to reflect the new Care Quality Commission (CQC) fundamental standard on visiting and accompanying in health and care settings (Regulation 9A) which requires, among other things, that care home residents must be facilitated to receive visits, and not discouraged from taking visits out of the care home.

Information on ordering free PPE has been removed to reflect the scheme to provide free PPE for COVID-19 needs coming to an end on 31 March 2024. Providers should ensure that they have arrangements in place to access and order PPE for staff to use in line with guidance recommendations. Please refer to the PPE Transition web page for further details.

Introduction

This guidance provides information on infection prevention and control (IPC) measures for ARI, including COVID-19. It applies to adult social care providers, managers of adult social care services and adult social care staff in England.

The guidance also contains information that is relevant to local authorities, NHS services, service users, personal assistants, unpaid carers and visitors in adult social care settings and services in England.

This guidance is consistent with the approach of managing COVID-19 increasingly in line with other ARIs, made possible by high vaccination coverage, high immunity amongst the population, and increased access to COVID-19 treatments.

This document should be read alongside the Infection prevention and control: resource for adult social care guidance, which contains best practice on general IPC.

NHS commissioned services should refer also to the NHS England National infection prevention and control manual (NIPCM) for England.

Definitions

Acute respiratory infection (ARI) is defined as the acute onset of one or more of the respiratory symptoms listed at People with symptoms of a respiratory infection including COVID-19 and a clinician’s judgement that the illness is due to a viral acute respiratory infection (for example COVID-19, flu, respiratory syncytial virus (RSV)).

Aerosol generating procedure (AGP) is a medical procedure that can cause the release of infectious particles from the respiratory tract of a person with an ARI and increase the risk of an infection spreading to those close by. In ASC, AGPs are undertaken in a variety of settings by specifically trained staff. Information on procedures that are considered AGPs is available in the NHS England National infection prevention and control manual.

Care home services (with or without nursing) are places where personal care and accommodation are provided together. People may live in the service for short or long periods. For many people, it is their sole place of residence and so it becomes their home, although they do not legally own or rent it. Both the care that people receive and the premises are regulated by the CQC. Refer to CQC’s service types for further details.

Extra care housing services covers many different arrangements. Usually, they consist of purpose-built accommodation in which varying amounts of care and support can be offered, and where some services and facilities are shared. The care that people receive is regulated by the CQC, but the accommodation is not. Refer to CQC’s service types for further details.

Supported living services involve a person living in their own home and receiving care and/or support in order to promote their independence. The care they receive is regulated by the CQC, but the accommodation is not. The support that people receive is continuous, but is tailored to their individual needs. It aims to enable the person to be as autonomous and independent as possible, and usually involves social support rather than medical care. Refer to CQC’s service types for further details.

Hierarchy of controls is an overarching approach to reducing risk of harm at work, including infection risk, as defined by the Health and Safety Executive (HSE). Advice on the hierarchy of controls implementation in social care settings is available in the Infection prevention and control: resource for adult social care

Personal assistant is a carer paid by an individual needing care, or their family, not through a CQC-regulated service.

Standard infection control precautions (SICPs) are basic IPC measures that should be used all the time in the health and care sector to reduce the risk of transmitting infections. More information on SICPs is available in the Infection prevention and control: resource for adult social care.

Unpaid carer is anyone, including children and adults, who looks after a family member, partner or friend who needs help because of their illness, frailty, disability, a mental health problem or an addiction. The care they give is unpaid. When we refer to carers in this document, this is inclusive of both adult and young carers. Refer to NHS England’s Commissioning for carers for further details.

Symptoms of acute respiratory infection

The common symptoms of ARI are listed at People with symptoms of a respiratory infection including COVID-19.

It can be difficult to distinguish between COVID-19, flu and illness caused by other respiratory viruses by symptoms alone. This may be more difficult among those receiving care. Adults with cognitive conditions such as dementia may have a reduced ability to recognise or communicate when they feel unwell, and older adults often do not present with the common symptoms of ARI if they have flu or COVID-19. It is therefore important to consider the possibility of ARI if there is a sudden deterioration in physical health or mental ability, with or without fever, in the absence of a known cause.

Unwell service users or staff may require a clinical review if symptoms persist for longer than expected or worsen. Antibiotics are not recommended for viral respiratory infections. However, antibiotics may be prescribed by an appropriate clinician if a bacterial chest infection is suspected.

In case of clinical deterioration or life-threatening symptoms, there should be no delay in contacting the GP, NHS 111 or emergency services as appropriate. If admission to hospital is required for any reason, inform the healthcare provider about any suspected or confirmed infection prior to hospital transfer.

How to be prepared for ARIs

The best way to reduce the spread and mitigate the harm of ARIs is to combine standard infection prevention and control precautions (SICPs) with vaccinations, available medical treatments, and proportionate outbreak management.

Ensure best IPC practice at all times

Preventing and reducing the spread of ARIs is key to the health and wellbeing of service users and staff in adult social care. SICPs are basic IPC measures that should be used all the time to reduce the risk of transmitting infections.

SICPs include:

• hand hygiene between tasks and between service users with soap and water or alcohol-based hand rub
• respiratory and cough hygiene (catch it, bin it, kill it!)
• regularly letting fresh air into rooms and shared areas (for more information on ventilation, see guidance on Ventilation to reduce the spread of respiratory infections, including COVID-19)
• cleaning of shared equipment, especially after use
• regular cleaning of the environment with particular attention to frequently touched surfaces and shared areas
• appropriate use of personal protective equipment (PPE)
• correct handling and segregation of waste and infectious linen

Adult social care clients should also be supported to contribute to SICPs by handwashing, cough hygiene and other simple measures as appropriate.

Further details on SICPs and best practice is available in the Infection prevention and control: resource for adult social care. All measures to prevent and manage infections should be risk assessed, prioritised in line with the hierarchy of controls (see Definitions section), and balanced to ensure the wellbeing of service users.

Encourage staff and service users to get vaccinated

Vaccination remains one of the most important defences against both COVID-19 and flu, helping to reduce the risk of serious illness, hospitalisation and death.

It is important that all those who are eligible for vaccination, including health and social care workers, take up their offers as soon as they become available to help protect themselves and those around them.

Providers should take steps to support vaccination by:

• providing information on vaccination campaigns with question and answer leaflets, posters, and stickers available on campaigns via the DHSC campaign resource centre
• commencing the consent process for residents in good time to maximise uptake for eligible people in residential care settings
• encouraging staff to book their vaccinations as soon as offers become available

COVID-19 vaccination

COVID-19 vaccines are offered during seasonal campaigns to those at high risk of serious disease from COVID-19 and who are therefore most likely to benefit from vaccination. Additional vaccination doses may be available outside seasonal campaigns to severely immunosuppressed individuals, in line with Green Book Chapter 14a COVID-19 recommendations.

COVID-19 vaccines are also available for health and social care workers to protect staff from serious disease and social care services from COVID-19 related staff absences over winter.

Carers are also eligible for COVID-19 vaccines, which reduce the risk of becoming seriously unwell.

Latest information on COVID-19 vaccine campaigns and COVID-19 vaccination programme.

Flu vaccination

Flu vaccination is an important defence against severe outcomes caused by the flu virus and reduces the risk of co-infection with COVID-19 and flu. People who are at higher risk of flu-associated serious illness and death, including older people and those in clinical risk groups, continue to be prioritised in seasonal campaigns for vaccination.

Frontline social care workers, including both clinical and non-clinical staff who have contact with people with care and support needs, should also be made aware of the flu vaccination offer, when available, by their employer.

Carers are also eligible for flu vaccines, which reduce the risk of becoming seriously unwell. See more information about flu vaccinations for carers.

Separate advice on flu vaccination is available for social care providers and staff.

Other vaccinations

Vaccination against pneumococcal infection can reduce the risk of bacterial pneumonia following on from a viral ARI. This is provided by GP surgeries who will have records of whether a service user’s vaccination is up to date. More information is available at Pneumococcal vaccine.

Identify people eligible for treatments

COVID-19 treatments

People who are at higher risk of severe outcomes from COVID-19 may be eligible for COVID-19 treatments if they become unwell.

People who are potentially eligible for COVID-19 treatments were previously digitally identified by their NHS records where possible. These individuals should have received a letter from the NHS explaining how to access COVID-19 treatments.

The process changed on 27 June 2023. Since June 2023, individuals who are newly eligible for access to LFD tests should be made aware of eligibility for COVID-19 treatments by their doctor or specialist at the point they are diagnosed with a qualifying condition or start a qualifying treatment.

If someone who is eligible for COVID-19 treatments develops COVID-19 symptoms, they should be tested as soon as possible with a LFD test. LFD tests taken to facilitate COVID-19 treatments should now be ordered via NHS routes, outlined in the section ‘Make sure you have COVID-19 tests available and in date’.

If someone who may be eligible for COVID-19 treatments tests positive for COVID-19, adult social care providers should organise an assessment for COVID-19 treatments for them. If in doubt, the adult social care provider should contact the local integrated care board (ICB) who can advise on how to arrange an assessment of eligibility for COVID-19 treatments. See NHS guidance on COVID-19 treatments for more information.

Local NHS organisations are responsible for arranging COVID-19 treatments. The way people access treatments may depend on where they live. Please refer to your local ICB for more information on local arrangements.

Treatments are most effective if started early and ideally provided within 5 days of symptom onset. It is therefore essential to test eligible people with symptoms as soon as possible so that they can access treatments in time if they test positive for COVID-19.

Staff providing care to people outside of residential care settings can help to support individuals to access tests and treatment for those eligible for COVID-19 treatments. More information is available at Treatments for COVID-19.

Flu antivirals

Antivirals for the treatment and prevention of flu work best when people start them within 2 days of becoming unwell or being in close contact with a person with flu. Flu antivirals in care homes may be recommended by the UK Health Security Agency (UKHSA) HPT when multiple people develop symptoms of ARI. Two or more linked cases of ARI should be promptly notified to the HPT to enable timely access to flu antivirals, if required. Refer to section ‘If multiple people have symptoms of acute respiratory infection in a care home’ for more information.

Information for clinicians on individual patient eligibility for flu antivirals treatment and prophylaxis is available at Influenza: treatment and prophylaxis using anti-viral agents.

Make sure you have COVID-19 tests available and in date  

How to access tests for people eligible for COVID-19 treatments in a residential care setting

Care providers can access tests on behalf of service users who are eligible for COVID-19 treatments and therefore, eligible for symptomatic testing.

Tests for this purpose are supplied by the NHS and should be accessed from a local pharmacy. Providers should speak to their usual pharmacy (for example those that provide residents’ medicines) or other local pharmacy to discuss access arrangements and whether the pharmacy is able to deliver tests in addition to collection options.

Pharmacies may ask questions about an individual’s medical history to confirm eligibility for free tests and update patient records for future test orders.

Providers accessing tests on behalf of their service users should provide the pharmacy with the details of eligible individuals where required, including any relevant letters or e-mails about COVID-19 treatments, if these are available. The required details include:

• medical conditions that indicate the service user is eligible
• the service user’s NHS number (if available)
• the service user’s full name
• the service user’s date of birth
• the address of the care setting

Providers should ensure that there are at least 3 tests available per eligible individual to enable them to test for 3 consecutive days if they develop symptoms of acute respiratory infection. 

More details from the NHS about this service can be viewed here, NHS England » NHS Lateral Flow Device (LFD) Tests Supply Service: Advanced Service and more information on availability of testing for treatments is available at Who can get a free NHS COVID-19 rapid lateral flow test.

A provider’s usual pharmacy may be able to provide details on which other local pharmacies are offering this service if they do not hold stock. It is important to plan ahead and make sure there are always sufficient test kits in the home in advance. For further questions about COVID-19 treatments, please refer to the local ICB.

How to access tests for people eligible for COVID-19 treatments who do not live in a residential care setting

People receiving social care who do not live in a care home and are eligible for COVID-19 treatments can access free COVID-19 tests via the NHS and should be supported to do so where necessary. Your local ICB can give you more information.

More information is also available at NHS guidance on COVID-19 treatments.

How to access tests for outbreak testing in a care home

COVID-19 LFD tests for testing during a suspected outbreak are no longer available from UKHSA. Care homes with a suspected outbreak of ARI should now discuss with their HPT who can arrange multiplex PCR testing.

How and when to record test results

A record should be kept of COVID-19 and other ARI test results when HPTs or other local partners advise additional testing.

Under Regulation 4A of The Health Protection (Notification) Regulations 2010, care homes are still required to report positive, negative and void LFD test results where they have assisted residents to take an LFD.

To support care homes in being able to meet their Regulation 4A duty, the UKHSA multiple registration spreadsheet will remain available for care homes to report COVID-19 LFD test results. Care homes are still able to use this route to report the result of LFD tests that have not been provided to the care home directly by UKHSA.

It is important to note that the registration of a positive COVID-19 LFD test result will not lead to a COVID-19 treatment being prescribed. To support residents and clients to access COVID-19 treatments, follow the guidance issued by the NHS.

The care home should notify the UKHSA HPT (or other local partner) if a COVID-19 or other ARI outbreak is suspected, in line with the advice in the section If multiple residents have symptoms of acute respiratory infection in a care home.

Ensure staff know how to recognise, monitor and escalate worsening symptoms of acute respiratory infection

Providers should ensure that care staff are able to recognise and escalate symptoms of ARI and can follow the advice in section Symptoms of acute respiratory infection.

Additionally, staff should know that hypoxia (low oxygen levels) is one of the key warning signs of a deterioration in ARIs and can indicate that further medical review and/or hospital admission (where appropriate) is required.

Pulse oximeters may be available to care homes through their named clinical lead, or local ICB, as part of COVID-19 oximetry at home. One oximeter per 10 beds with a minimum of 2 oximeters per home, regardless of the size of the home, is recommended. For example, care homes with less than 10 beds should receive 2 pulse oximeters. Equipment which is used to support the monitoring of residents will need to meet IPC and decontamination standards and guidance.

The Care Provider Alliance has produced guidance on COVID-19 oximetry for care home residents. NHS England (NHSE) and West of England Academic Health Science Network (AHSN) have also produced training and support for care home staff using pulse oximetry.

Care homes should have a weekly check-in with the home’s Primary Care Network (PCN) or multidisciplinary team, who can support staff to understand the RESTORE2 and NEWS2 scoring system as a way of monitoring residents with symptoms. More information about the Primary Care Network.

If a patient’s symptoms worsen, it is important to contact NHS 111 or the registered GP for a clinical assessment either by phone, telemedicine or face to face.

The resident’s GP should give further advice on escalation and ensuring decisions are made in the context of the resident’s advanced care plan. In a medical emergency, the care home should dial 999.

Ensure PPE is available and people know how and when to use it

All care staff should use appropriate PPE in line with risk assessments and the hierarchy of controls to reduce the spread of infection and other risks associated with certain care tasks. Unpaid carers, personal assistants and visitors to residential care settings should also use appropriate PPE where advised.

This guidance summarises what PPE should be worn in addition to recommendations for SICPs (for example, when there is a risk of contact with blood or body fluids). This is also summarised in the table on PPE recommendations for ARIs.  

It is important people know how to use PPE properly and follow instructions for putting on (donning) and taking off (doffing). It may be useful to put up the donning and doffing posters to help people use PPE correctly. They may also be used for training.

See poster PPE requirements when caring for a person with suspected or confirmed ARI

For PPE to be effective:

• all staff should be trained in the correct use, safe donning and doffing and disposal of PPE
• visitors to care homes, personal assistants and unpaid carers should be advised on the correct use of PPE and service users should be informed of why PPE is being used
• people should clean their hands before putting on and after taking off PPE
• PPE should not be re-used unless they are marked as reusable and are appropriately decontaminated between use
• PPE should be put on and removed at least one metre away from care recipients

Infectious clinical waste including waste visibly contaminated with respiratory secretions (such as sputum or mucus from the mouth and nose) generated from an individual who is considered infectious, should be treated like any other infectious clinical waste, following national regulations and in line with the IPC resource for adult social care.

When and how to use face masks

Care workers and visitors to care homes do not routinely need to wear a face mask in care settings or when providing care in people’s own homes.

However, Type IIR fluid-repellent surgical masks should be worn:

• if the person being cared for has symptoms of ARI
• when cleaning the room of a person with symptoms of ARI
• if there is an outbreak of ARI in a care home and the local risk assessment favours the introduction of universal masking as one of the outbreak control measures
• if the person being cared for would prefer staff or visitors to wear a mask while providing them with care or visiting

A local risk assessment should be undertaken by a provider when considering how to support the personal preferences of care workers and visitors who wish to wear a face mask in situations beyond the above recommendations.

Providers should consider mitigations if a person receiving care finds that the use of face masks impairs communication or is distressing. This may particularly be the case when caring for people with learning disabilities, cognitive conditions such as dementia, or people who rely on lip reading or facial recognition.

It may be appropriate in certain circumstances to consider using transparent face masks. Only transparent masks compliant with the Medicines and Healthcare products Regulatory Agency (MHRA) standards can be considered as an alternative to Type IIR surgical masks.  

You should ensure that face masks are:

• well fitted to cover the nose, mouth and chin
• worn according to the manufacturer’s recommendations (for example checking the coloured side is worn outwards, unless the manufacturer states otherwise)
• worn by staff only following a risk assessment
• not allowed to dangle around the neck at any time, or rest on the forehead or under the chin
• not touched once put on
• removed and disposed of appropriately, with the wearer cleaning their hands before removal and after disposal
• changed if either moist, damaged, contaminated or soiled, uncomfortable to wear
• changed between break times and between different people’s homes
• changed after providing care for someone or a single cohort of several people with symptoms of ARI

People should not wear masks which have exhalation valves or vents. Cloth face coverings should not be used in situations where surgical masks are advised in adult social care settings.

Type IIR fluid-repellent masks

Type IIR fluid repellent surgical masks are recommended for use in adult social care. This is in line with the PPE recommendations for ARIs in adult social care.

These masks protect the wearer against blood or body fluid splashes, and against respiratory droplets. They also protect others from the wearer’s respiratory droplets.

Type I and Type II masks

These do not meet the requirements of PPE. They are worn only for source control to protect others from the wearer’s respiratory droplets. Type I and Type II masks can be used only in situations where the use of masks at all times is introduced during an outbreak and the care worker is not in close contact with symptomatic individuals.

Filtering face piece class 3 (FFP3) respirators for use during AGPs

FFP3 respirators are required when undertaking an aerosol generating procedure (AGP – see Definitions section) on a person with symptoms of ARI or another infection spread by the airborne or droplet route. FFP3 respirators should be removed and disposed of outside of the room where the AGP was carried out, or when leaving the house of a care recipient. For donning and doffing instructions for AGPs refer to the PPE guidance for AGPs.

The use of FFP3s is governed by health and safety regulations, and they should be fit tested to the user to ensure the required protection is provided. FFP3 respirators must be fit checked each time they are used. HSE provides information and tools to help select and manage the use of respiratory protective equipment (RPE).

When and how to use gloves and aprons

Gloves and aprons should be used when there is a risk of exposure to mucous membranes, blood or body fluids.

Aprons and gloves should be worn if carrying out an AGP on an individual. If there is an extensive risk of splashing, fluid repellent gowns should be worn instead of aprons.

When required, gloves should be changed between tasks. Hand hygiene should be performed between tasks, after removing and disposing of gloves, and upon leaving the room or care recipient’s home. Improper use of gloves may provide a false sense of reassurance to staff and visitors and reduce compliance with hand hygiene recommendations.

The Royal College of Nursing’s (RCN) Glove awareness campaign on safe and sustainable glove use, in collaboration with NHSE, advocates for risk assessment before deciding to use gloves. As part of their campaign, the RCN provides free access to an online course designed for all staff and care settings to reduce inappropriate glove use and promote better care for their skin. Further resources on non-sterile glove use are also freely available. 

When and how to use eye protection

Eye protection should be worn:

• when within one metre of a person with ARI infection, including when cleaning their room
• if carrying out an AGP on an individual. If a non-fluid resistant FFP3 is worn, use a full-face visor covering the eyes, nose and mouth

Eye protection should:

• be removed upon leaving the room or leaving the home of a care recipient
• be removed when taking a break (to drink, eat, use the toilet)
• be discarded and replaced if damaged
• not be worn around the neck or top of the head
• be adjusted or discarded and replaced as appropriate if uncomfortable
• be cleaned and disinfected between use or if visibly dirty and stored safely if reusable
• be discarded after use or if visibly dirty if single use

Prescription spectacles do not provide adequate eye protection; therefore, those wearing spectacles should use a visor for eye protection. 

If a service user has symptoms of acute respiratory infection

Support the service user to stay away from others

Care home residents

In care homes, residents with symptoms of ARI and who have a high temperature or do not feel well enough to do their usual activities should be supported to stay away from others to protect residents who may be at risk of severe ARI outcomes.

Residents who are not eligible for COVID-19 treatments should be supported to stay away from others until they no longer have a high temperature and no longer feel unwell.

Residents who are eligible for COVID-19 treatments who test positive for COVID-19 should continue to be supported to stay away from others and follow the advice in the ‘If a service user tests positive for ARI’ section.

Service users not in a care home

Adult social care service users not in a care home who have ARI and who have a high temperature or do not feel well enough to do their usual activities should follow the guidance for people with symptoms of a respiratory infection.

They should avoid contact with other people until they no longer have a high temperature or feel unwell. They should only test if eligible for COVID-19 treatments, or on the advice of a clinician.

Ensure the service user’s wellbeing

Care home residents

Providers should ensure the wellbeing of residents who are being supported to stay away from others.

The care home manager should ensure that residents who undergo testing for ARI are informed of their test results. They should also ensure that staff are informed of the test results of residents and any relevant measures that have been implemented.  Residents’ loved ones should be informed too if this is the resident’s wish and does not breach confidentiality arrangements.

Residents with symptoms of ARI should still be able to receive visitors inside the care home with appropriate IPC precautions. For advice on visiting refer to Encourage and facilitate visitors and visits out.

Residents should be supported to safely access the toilet and shower rooms outside of their room when en-suite facilities are not available. The resident should wash their hands, wear a face mask upon leaving the room if tolerated, and be supported to stay away from other residents while accessing the services. Shared toilet and shower facilities should be ventilated and cleaned with chlorine 1,000 parts per million (ppm) (or other product active against respiratory viruses) after use by a resident who is recommended to stay away from others.

Residents should also be supported to go into outdoor spaces within the care home grounds through a route where they will not be in contact with other residents.

Monitor the service user

Care home residents

Staff should be able to monitor residents’ symptoms, escalate any concern and facilitate a clinical review as required, in line with local protocols.

Ensure IPC precautions are followed

If a service user develops symptoms of ARI, remind staff of the standard IPC precautions that can help prevent further transmission.

Additionally, regularly let fresh air in their room, clean the room, the toilet and shower facilities with 1,000 ppm chlorine-based solutions (or other product active against respiratory viruses) and consider an enhanced cleaning schedule of frequently touched surfaces.

Staff should wear appropriate PPE as outlined in the section ‘Ensure PPE is available’.

Visitors and carers should also be given information on hand hygiene, PPE, and any other required measures (for example letting fresh air in) when visiting or caring for a service user with symptoms of ARI who is being supported to avoid contact with other people. These measures should also be explained to residents where appropriate, and they should be supported to follow them.

Test for COVID-19 if the service user is eligible for COVID-19 treatments

Check whether the symptomatic service user is eligible for COVID-19 treatments. People who are not eligible for COVID-19 treatments no longer need to test if they develop symptoms of a respiratory infection, unless specifically advised by the HPT or other local partner.

People who are eligible for COVID-19 treatments and have symptoms of acute respiratory infection should take a LFD test immediately and follow the guidance for people who are eligible for COVID-19 treatments.

If a service user tests positive for COVID-19, follow the advice in the section titled If a service user tests positive for acute respiratory infection. If all COVID-19 tests are negative, continue to follow the advice on ‘Service users with symptoms of acute respiratory infection’. In care homes, also consider whether flu testing is appropriate in case of multiple symptomatic service users and in line with the next section on flu testing and antivirals.

Consider flu testing and antivirals

Flu testing and antivirals are not routinely available for all service users with symptoms of ARI. However, in care homes, flu testing and antivirals can be recommended by the UKHSA HPT in case of a suspected ARI outbreak, following a risk assessment. Contact your local UKHSA HPT if flu is suspected. The UKHSA HPT contact details are available at Find your local health protection team in England. GPs can also prescribe antivirals directly for treatment of individual cases and prevention in close contacts when DHSC has advised that flu is circulating nationally.

For more information on flu antivirals and on what to do in a care home with a suspected ARI outbreak other than COVID-19 (for example, flu, RSV), please see section If multiple residents have symptoms of acute respiratory infection in a care home.

If a service user tests positive for acute respiratory infection

Providers should continue to follow the guidance in the section If a service user has symptoms of acute respiratory infection to ensure IPC precautions continue to be followed. 

Arrange an assessment for appropriate treatments

If a service user tests positive for COVID-19

Service users who test positive for COVID-19 who are eligible for COVID-19 treatments should be supported to access appropriate treatments as quickly as possible. Further detail is outlined in the section ‘Identify people eligible for treatments’ above.

If a service user tests positive for another acute respiratory infection

A GP, hospital, or HPT may request a multiplex PCR test for a care home resident for diagnostic reasons or during a suspected ARI outbreak. If the resident tests positive, follow the treatment advice of the GP or hospital and inform the HPT. Follow the HPT advice for the service user management. If in a care home there is more than one symptomatic resident within 5 days, refer to section If multiple residents have symptoms of acute respiratory infection in a care home.

Care home residents who test positive for flu may require flu antivirals, and preventative antivirals may be necessary for other exposed residents. The UKHSA HPT will be able to advise on this.

Support the service user to stay away from others

Care home residents with COVID-19 or flu

Care home residents who test positive for COVID-19 should be supported to stay away from others for a minimum of 5 days after the onset of respiratory symptoms. After 5 days, the resident can return to their normal activities if they feel well and no longer have a high temperature.

If the resident is still unwell after 5 days, they should be supported to continue to stay away from others until they feel well and they no longer have a high temperature, and for usually no longer than 10 days in total. Seek clinical advice for anyone who is still unwell or has a temperature after 10 days, if not done already.

Follow the UKHSA HPT advice on the management of care home residents who test positive for other acute respiratory viruses, including flu.

How to readmit a care home resident who tests positive for acute respiratory infection while in hospital

If a care home resident tested positive for ARI during an admission in hospital (for example inpatient, emergency department), providers should record the positive test date. Based on the positive test date, providers can estimate if and for how long the resident needs to be supported to stay away from others when returning to the care home.

A risk assessment should be undertaken to determine where the ARI was acquired. If the infection was likely acquired in the care home, and there is more than one symptomatic person within 5 days, follow the advice in section If multiple residents have symptoms of acute respiratory infection in a care home.

If a service user outside of a care home tests positive for COVID-19

Service users receiving care outside of care homes who test positive for COVID-19 should follow the guidance for people who have a positive COVID-19 test result. They should not normally be asked to test for another ARI, unless requested by the HPT.

Ensure the service user’s wellbeing and monitor the symptoms

Care home residents

Providers should follow the guidance in the section If a service user has symptoms of acute respiratory infection on ensuring the wellbeing of care home residents.

The provider should also inform the resident’s GP of a positive test result so that they are aware. Providers should follow the guidance in the section regarding monitoring residents symptoms’ and escalate any concern as per local protocols.

If a staff member has symptoms of acute respiratory infection

Support symptomatic staff to stay away from work

Staff who have symptoms of respiratory infection and who have a high temperature or do not feel well enough to go to work are advised to stay away from work and try to avoid contact with other people. They should not return to work until they no longer have a high temperature (if they had one) or until they no longer feel unwell.

Managers should undertake a risk assessment before staff return to work in line with normal return to work processes.

The staff member should also follow the guidance for people with symptoms of a respiratory infection including COVID-19.

Staff testing for COVID-19 (only if eligible for COVID-19 treatments)

Staff members do not need to take a COVID-19 test if they develop symptoms of a respiratory infection unless they are eligible for COVID-19 treatments. Staff do not need to take tests for any other ARIs, unless indicated by a clinician.

Staff members who are eligible for COVID-19 treatments and have symptoms of a respiratory infection should take an LFD test immediately and follow the guidance for people who are eligible for COVID-19 treatments.

If a staff member tests positive for COVID-19

Staff members should only take a COVID-19 test if they have respiratory symptoms and are eligible for COVID-19 treatments, or if advised by an HPT.

If a staff member tests positive for COVID-19, they should stay away from work for a minimum of 5 days from onset of symptoms, or the day they took their test if they do not have symptoms, and follow the guidance for people who have a positive COVID-19 test result.

After 5 days, they can return to work once they feel well, and do not have a high temperature. If they are still displaying respiratory symptoms when they are due to return to work, they should speak to their line manager who should undertake a risk assessment, which may in exceptional circumstances require medical advice.

If an individual is a contact of a confirmed COVID-19 case

Individuals do not need to be tested if they have been in contact with someone confirmed to have COVID-19.

People who are household or overnight contacts should follow guidance for the general public set out in Guidance for people with symptoms of a respiratory infection including COVID-19.

If multiple residents have symptoms of acute respiratory infection in a care home

An ARI outbreak may be suspected when there is an increase in the number of residents displaying symptoms of a respiratory infection.

An ARI outbreak consists of 2 or more positive or clinically suspected linked cases of ARI, within the same setting within a 5-day period. This means the cases may be linked to each other and transmission within the care setting may have occurred.

Undertake a risk assessment and notify the HPT of a suspected ARI outbreak

If 2 or more linked care home residents develop symptoms of a respiratory infection within 5 days of each other, the care home should undertake a risk assessment as soon as possible. The risk assessment should help to determine if there is an outbreak and if control measures are needed. The provider should inform the HPT (or other local partner) of a suspected outbreak. However, they are not required to wait for advice from the HPT (or other local partner) if they feel they are able to initiate the risk assessment and the control measures independently.

The risk assessment can be undertaken directly by the care home provider using the expertise of relevant care home staff. Further support is also available from the local HPT or other local partner, according to local protocols, at the care home’s request.

The HPT will advise on the use of multiplex PCR to test up to 5 linked symptomatic residents with most recent symptom onset. Any symptomatic residents eligible for COVID-19 treatments should also be tested as soon as possible when they develop symptoms of an ARI using COVID-19 LFD tests obtained for this purpose, even if they are also tested by PCR. If further residents develop respiratory symptoms, they should only be tested if they are eligible for COVID-19 treatments or if advised by the HPT.

The risk assessment should determine whether the cases are likely to have been the result of transmission within the care home, and if cases are therefore linked. In determining whether they are linked, the risk assessment should consider:

• whether there is a known source of infection
• whether there was contact between residents while one or more individuals had suspected or confirmed ARI
• whether there is a staff member in common for the resident cases
• whether the cases all live in the same area of the home (for example floor or unit) or if they are in separate areas and do not have other links
• whether the first identified case originated in the setting, for example if the resident was in the setting up to 5 days prior to symptoms and/or a positive test

Cases would be less likely to be considered linked if:

• symptom onset was more than 5 days apart
• the residents had no contact with each other in the last 5 days

It should be noted that residents in some care homes, particularly homes for younger adults under 65 years, may have extensive community contacts for education or training, leisure, or work. This should be considered when assessing the likelihood of cases being linked.

For scenarios where a home is divided into distinct operational units with multiple cases in each area, and independent concurrent outbreaks may have arisen, the HPT may advise that up to 5 tests should be done for each area, where feasible.

Staff should not generally be among cases prioritised for outbreak risk assessment testing. Symptomatic staff are advised to not work until they have recovered from acute symptoms, therefore they should not be on-site and should be less available for testing. Staff may also have different pathogen exposure (for example from household members) and so their results may be less informative than those from resident testing.

Review ARI test results

If at least one test result is positive

If the risk assessment determines that there are 2 or more linked symptomatic residents within a 5-day period, and the testing of up to 5 residents shows that COVID-19 or other ARI is circulating in the same setting, providers should continue to follow advice in If a service user tests positive for acute respiratory infection and refer to the section below to consider the ‘implementation of outbreak control measures’.

The provider should also notify the HPT. The HPT may advise on additional control measures. The HPT will be also able to advise if flu antivirals are recommended for symptomatic residents or if flu antiviral prophylaxis is necessary for the other residents at risk of severe outcomes.

If test results are all negative

If residents are displaying symptoms of acute respiratory infection and all the ARI tests from up to 5 suspected cases with most recent symptoms onset are negative, continue to follow the advice in the section ‘If a service user has symptoms of acute respiratory infection’.   

When further assessment may be necessary

Further clinical assessment of the symptoms may be necessary if the residents remain unwell. If co-infection (for example COVID-19 and flu) is suspected after clinical assessment, notify the HPT to discuss access to further testing.

Request further advice if there are concerns

The care home can contact the HPT (or other local partner) for advice on further measures. These may include wider testing if there are specific issues of concern, such as:

• greater severity of illness than expected
• more deaths or hospitalisations than expected
• rapidly increasing cases despite control measures
• a suspected outbreak of 2 ARIs (for example flu alongside COVID-19)

Providers should seek advice from the relevant local authority contact if there are operational issues such as staffing shortages or concerns about safety.

Wider outbreak testing should only be done if advised by the HPT. The HPT may also indicate if a COVID-19 variant of interest or variant of concern is suspected.

Implement outbreak control measures

Following local risk assessment, outbreak control measures should be considered to manage ARI outbreaks. Outbreak control measures should be proportionate, risk assessed and time limited.

Examples of outbreak control measures may include and are not limited to:

• increase cleaning frequency of frequently touched surfaces in shared areas
• use 1,000 ppm chlorine-based solution or other product effective against respiratory viruses to clean the room, toilet and shower services used by symptomatic service users
• reminders to regularly letting fresh air in, in all areas
• universal use of Type IIR fluid repellent surgical masks when providing care
• reminders on hand and respiratory hygiene
• proportionate reductions or postponement of communal activities
• monitor all residents for elevated temperature and other respiratory symptoms
• proportionate reductions in admissions which may include temporary closure of the home to further admissions
• restricting movement of staff who provide care, where possible, for example between wings, or between different care settings (for example for agency staff)
• cohorting of staff to care for symptomatic/positive or non-symptomatic/negative residents (where feasible and safe to do so)
• proportionate changes to visiting – this may include a reduction in the number of people entering and leaving a care home to reduce the spread of infection. Visiting should be facilitated unless there are exceptional circumstances, where facilitating a visit would pose a significant risk to the health or wellbeing of someone in the care home premises which cannot be mitigated through other precautions. End of life visits and visits from health professionals should always be facilitated, and CQC inspectors must be allowed entry to the care home

Any measures that the care home chooses to implement must be proportionate and risk-based and should consider resident’s wellbeing as well as the care home’s legal obligations. The care home manager should ensure staff, residents and their loved ones are informed of the outbreak and any relevant measures that have been implemented.

As noted above, where the local or national risk assessment indicates specific concerns, additional measures may be advised by the HPT or other local partner.

Lift outbreak control measures once no longer required

Outbreak control measures can be lifted 5 days after the onset of symptoms in the most recent symptomatic resident. A local risk assessment should underpin the decision to lift outbreak control measures. At this point, care homes should revert to the guidance for management of single cases in section If a service user has symptoms of acute respiratory infection.

All residents should be monitored for up to a further 5 days after this to ensure they can access appropriate treatments where necessary. Please refer to ‘Ensure staff know how to recognise, monitor and escalate worsening symptoms of acute respiratory infection’.

Further testing in an outbreak should only be done following an HPT risk assessment and on HPT advice in relation to specific concerns.

Admission of care home residents

Admission from acute hospitals

Asymptomatic individuals being discharged from hospital into a care home are no longer advised to be routinely tested with a COVID-19 LFD test before planned discharge. However, in conjunction with local care home providers, acute health providers should have trusted assessment arrangements to facilitate safe discharges as set out in the hospital discharge and community support guidance.

Together with the care home, hospitals should assess the risk in the period before planned discharge, seeking advice on proposed changes to testing arrangements from local authority public health teams or UKHSA HPTs, if needed. Following discussion with care home providers and any advice from public health teams or HPTs, hospitals may decide to undertake an LFD test, for example if there is a local outbreak within the hospital setting. This test should be provided and done by the hospital. The care provider should speak to the hospital to raise any concerns about a planned discharge. Where a care provider is providing services commissioned by a local authority or the NHS and has concerns about a planned discharge that cannot be resolved with the acute hospital provider, they may wish to contact the relevant commissioner.

There is no need to test for flu or other respiratory viruses prior to discharge, unless clinically required.

Individuals who are tested before discharge into a care home who test positive for an ARI can be admitted to the care home if the home is satisfied that they can be cared for safely. Those who are admitted with a positive test result should be supported to stay away from other residents on arrival and should follow the guidance section ‘If a service user tests positive for acute respiratory infection’. They should be supported to stay away from others for 5 days from the day of symptom onset, or from the day the test was taken if they did not have any symptoms.

The recommended period to stay away from others does not restart when they are admitted into the care home, and further routine testing is not required. Medical advice should be sought if there is concern about their condition.

For residents discharged from hospital who tested positive for COVID-19 but had no symptoms, they should be supported to stay away from others for 5 days from the day the test was taken.

If there were signs of a new variant emerging or an increase in ARI sufficient to impact on health and social care outcomes, UKHSA would manage any wider response through standard incident response structures. This would include the provision of public health advice to mitigate any risk, including the possible re-introduction of asymptomatic discharge testing if appropriate, alongside other IPC measures.

UKHSA’s usual incident response procedures enable local authorities, NHS providers, and care providers to alert the relevant UKHSA Regional Response Centre or HPT of an incident that may require assessment and management. UKHSA regional teams will escalate nationally as required.

Admission from community settings

Individuals admitted from the community or other care settings do not need to be tested for ARI before they are admitted into the care home.

Encourage and facilitate visitors and visits out

Contact with relatives and friends is fundamental to care home residents’ health and wellbeing and visiting should be supported.

The CQC fundamental standard on visiting and accompanying (Regulation 9A) requires that care home residents must be facilitated to receive visits unless there are exceptional circumstances. If necessary and proportionate, precautions should be put in place to enable visits to happen safely. This is to ensure that people staying in a care home can see people they want to see. The regulation also requires that residents are not discouraged from taking visits out of the care home unless there are exceptional circumstances.

During an infectious disease outbreak, outbreak control measures may include a reduction in the number of people entering and leaving a care home to reduce the spread of infection, subject to an individual risk assessment. Visiting should only be restricted in exceptional circumstances, where facilitating a visit would pose a significant risk to the health or wellbeing of someone in the care home premises, which cannot be mitigated through other precautions. When the specific circumstances of an outbreak require this, any advice on reducing visiting should always be time limited, proportionate to each specific outbreak and risk based.

All decisions made and advice provided should be documented. Even in exceptional circumstances, end of life visits and visits from health professionals should be facilitated, and CQC inspectors must be allowed entry to the care home. They should be informed of the risks and enabled to follow appropriate IPC precautions.

Providers cannot prevent residents from leaving the care home unless there is a lawful basis for restriction of that person’s movements in accordance with the Deprivation of Liberty Safeguards (DoLS). Care home residents should not usually be asked to avoid contact with others or to take any ARI test following visits out of the care home. Residents should not be discouraged from taking visits out of the care home unless there are exceptional circumstances. However, there may, in exceptional circumstances, be a need for proportionate precautions upon an individual’s return to protect the health and safety of other residents.

Precautions for visitors

Visitors should consider taking up any COVID-19 and flu vaccines they are eligible for. Visitors should not enter the care home if they are feeling unwell, even if they have tested negative for COVID-19 and have had any flu or COVID-19 vaccines they are eligible for. If visitors have symptoms of ARI, they should follow the guidance for people with symptoms of a respiratory infection.

It is also important that visitors follow the IPC processes put in place by the care home, such as practising hand hygiene and following the same PPE recommendations as staff.

Visitors should be warned of any ongoing outbreak and any symptomatic residents so that they are aware of the risks and can decide whether to go ahead with the visit or postpone if they wish to do so.

Additional requirements for face masks may be in place during a confirmed outbreak of ARI. This should be based on local assessments, considering any distress caused to residents or barriers to communication from the use of PPE.

If visitors are being asked to wear face masks, children under the age of 11 who are visiting may choose whether to wear a face mask. However, they should be encouraged to follow other IPC measures such as practising hand hygiene. Face masks for children under the age of 3 are not recommended.

Health, social care and other professionals may need to visit residents within care homes to provide services. Visiting professionals should follow the same PPE recommendations as other visitors.