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Management of UTI's in Elderly Residents

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Management of UTI's in Elderly Residents

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NHS England Workforce, Training and Education

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Out of hospital management of UTIs in elderly patients

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Guidance for management of outbreaks of respiratory illness in care homes 

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Guidance for management of outbreaks of respiratory illness in care homes 

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Guidance for outbreaks of respiratory illnesses in care homes 2024-25

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Introduction

Contact with relatives and friends is fundamental to care home residents' health and wellbeing. The right to respect for private and family life is a human right protected in law ( Article 8 of the European Convention on Human Rights.

There should not normally be any restrictions to visits into or out of a care home. However, during an infectious disease outbreak, health protection teams may in exceptional circumstances advise that providers reduce the number of people entering and leaving a care home to reduce the spread of infection. This should only happen if 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.

Aim of this guidance

This document provides general principles to support advice and decision making for anyone involved in the provision of advice to adult social care homes. It provides a review of the issues which should be considered in safely planning and protecting visiting during outbreaks of infectious illness.

Who these principles are for

These principles have been written for health protection practitioners and community infection prevention and control professionals, who have responsibility for advising on supporting safe visiting. They may also be useful for care home managers and providers who have responsibility for implementing outbreak management measures in adult social care homes.

Legal and regulatory context

From 6 April 2024, a new Care Quality Commission (CQC) fundamental standard on visiting and accompanying (Regulation 9A) requires that care home residents must be facilitated to receive visits, and not discouraged from taking visits out of the care home. If necessary and proportionate, precautions should be put in place to enable visits to happen safely.

The amendment to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 9A aims to make sure that:

people staying in a care home, hospital or hospice can receive visits from people they want to see

people living in a care home are not discouraged from making social visits outside the home

people attending hospital or hospice appointments who do not require an overnight stay are accompanied by a family member, friend or advocate if they want someone with them

Providers are not legally allowed to prevent residents from leaving the care home unless there is a lawful basis for restriction of that person's movements, and in accordance with the Deprivation of Liberty Safeguards ( DoLS). However, there might in exceptional circumstances be a need for proportionate precautions upon an individual's return.

In the specific circumstances of an infectious disease outbreak requiring precautions, the advice on reducing visiting should always be time limited, proportionate to each specific outbreak and risk based.

The following national guidance is available which includes advice on care home visiting during outbreaks of infectious illness:

National guidance containing advice on care home visiting is not provided for all infectious illnesses. However, some common principles can be applied across multiple scenarios. Principles which health protection, public health and infection prevention and control professionals can refer to when providing advice to care homes in the management of outbreaks are summarised below.

Principles for advice on visiting during an outbreak of infectious illness in a care home

These principles should be used when there is no national guidance on visiting for a specific infectious illness.

All decisions made and advice provided should be documented. Even in exceptional circumstances, end of life visits should be facilitated and CQC inspectors must be allowed entry to the care home.

Visiting should be facilitated unless there are exceptional circumstances, and providers should put in place necessary and proportionate precautions to enable a visit to take place safely. If exceptional circumstances apply, visits from friends and family should be assessed on an individual basis as to whether they should occur. It may be appropriate to reduce or postpone visits if a visit would pose a significant risk to the health, safety, or wellbeing of someone on the care home premises, which cannot be mitigated through other measures.

Residents' emotional wellbeing must be prioritised when any restrictions to visiting are considered as part of outbreak measures.

The aim of these principles is to:

protect the health of the residents, visitors, and staff in the care home, and enable those involved in visiting to take appropriate precautions to facilitate visits both in and out of the care home in a safe manner

enable residents, visitors and others involved in visiting to be actively involved in the decision-making process

reduce stress and anxiety for the resident and visitor by enabling visits

ensure advice is proportionate to the specific infection or situation

reduce the risk of infection being transmitted between residents and visitors in the care home

All visits into and out of the care home

1. Residents and visitors should be informed that there is an outbreak of infectious disease.

Visits into the care home

2. The risk to the visitor should be explained to them and to the resident they are visiting (where appropriate), especially if visiting a symptomatic resident.

3. Visitors should be given information on hand hygiene, personal protective equipment and any other measures that may reduce the risk of onward transmission. This could be in the form of written information, signs, or other appropriate means of communication. These measures should also be explained to residents (where appropriate).

4. People should not visit if they have symptoms of any infectious illness or if they consider themselves to be infectious for any reason, unless there are exceptional circumstances, such as end-of-life care. They should stop visiting for any required exclusion period (for example, 48 hours after recovery for gastrointestinal infections).

Further information on specific infectious illnesses is available in the UK Health Security Agency (UKHSA) Infectious Diseases A to Z and the NHS Health A to Z.

5. Social gatherings such as parties that bring together groups who would not normally socialise together should usually be postponed until the outbreak is over.

6. Visitors should not normally visit multiple residents during outbreaks. When this is necessary - for example, a minister of faith or a healthcare professional - they should as far as possible visit individuals considered most likely to be infectious last (for example, individuals with recent onset of symptoms). Appropriate infection prevention and control procedures should be used for each individual visit.

7. Visitors providing services other than health or social care, such as hairdressers or entertainers should usually be postponed until the outbreak is over.

8. Visiting that is required on grounds of compassion or health and safety should continue, even where exceptional circumstances apply. Examples include:

when a resident is approaching the end of life (see Next Phase Community Health Service End of Life Core Service framework) - this does not require a specific terminal diagnosis

when there would be distress or harm resulting from not having a visitor

when there are safeguarding concerns by family, provider, regulator, commissioner or any advocate for an individual resident

visits from healthcare professionals which, if delayed, would be detrimental to the resident

visits from social workers which, if delayed, would be detrimental to the resident

visits for religious or spiritual reasons

essential maintenance staff, for example, heating or water supply

visits from the Care Quality Commission inspector

9. It may be appropriate to reduce or postpone specific visits if a visit poses a significant risk to the health, safety, or wellbeing of someone on the premises and this cannot be mitigated through other precautions. Consider as part of a risk assessment:

very young (especially babies) and very elderly visitors who may be at increased risk

the risk of harm to the resident

the risk of visitors re-introducing the infection into the care home, particularly in relation to infections more likely to be spread by children

10. In very exceptional circumstances, it may be necessary to consider stopping most visits (for reasons other than on the above grounds of compassion or health and safety) for a limited period. Examples include:

when there is risk of severe harm to visitors from the infection

where an outbreak is not under control and there is current and significant risk of serious harm to visitors, residents and/or the wider population

Visits out of the care home (by residents)

11. Residents should be supported to make proportionate changes to daily activities, taking into account any advice for the general public. This is particularly important when considering visits to other social care settings such as day centres or another care home, as there may be a risk of the outbreak spreading into another setting. A risk assessment should be taken on an individual basis.

12. Residents (or their advocates) should be supported to consider the risks and benefits of visits outside of the care home, including:

if the resident is likely to be infectious to others

if the resident is well enough to undertake the visit

the risk of harm to those they are visiting

the risk of harm to the resident (consider other infections circulating in the local population)

13. When planning visits outside the care home, the following should be considered as part of a risk assessment:

communication of risk with the person being visited (if appropriate)

transport arrangements

escort requirements

advising the resident (or their advocates) to avoid crowded places

advising the resident (or their advocates) to avoid poorly ventilated spaces (particularly if the resident has symptoms of a respiratory infection)

advising the resident (or their advocates) on hygiene measures such as cleaning hands frequently, tissues, wearing a face covering (as appropriate)

14. If a resident has a health appointment, the health provider should be contacted prior to the appointment to risk assess and determine if attendance is appropriate.

If you have any questions about this guidance contact ASCTeam@ukhsa.gov.uk

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Supporting safer visiting in care homes during infectious illness outbreaks

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Principles to support decision making for those involved in safely planning and protecting visiting during outbreaks of infectious illness in adult social care.

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The Queen's Nursing Institute (QNI) has published a major new report on the effect of the Covid-19 pandemic on the UK's nursing and residential homes.

In May and June of 2020, a survey of the QNI's Care Home Nurses Network was carried out by the QNI International Community Nursing Observatory (ICNO) to understand more about the impact of Covid-19 on the Care Home Nurse workforce within the UK. This survey was launched in the early weeks of the pandemic in response to grave concerns about the safety of the workforce and the gaps in provision that it was facing. The survey responses confirm that for the majority of respondents, the pandemic has been a very challenging experience. They indicated that their work and wellbeing has been worse or much worse than at normal times, during the survey period.

Having to accept patients from hospitals with unknown Covid-19 status, being told about plans not to resuscitate residents without consulting families, residents or care home staff, lack of guidance on issues like personal protection and issues of poor access to pay if they became ill were some of the major issues the care home workforce faced during March and April 2020.

While two thirds of respondents said they 'always' had access to appropriate personal protective equipment (PPE) and most others said that it was usually available, a small minority were not provided with PPE and had to improvise, by obtaining it themselves or by making it. The need for appropriate PPE in care homes is of critical importance in staff and resident safety: 21% of respondents said that their home accepted people discharged from hospital who had tested positive for Covid-19.

The majority of survey respondents found it easy to access hospital care for their residents when this was required; however, a substantial minority found this difficult or very difficult. Additionally, a substantial number found it difficult to access District Nursing and GP services, which are universal parts of the National Health Service. In addition, many indicated that they were not able to access essential training from other health professionals at this time.

Some respondents refocused work to consider how they could improve on their approach to end of life care. Worryingly, some who responded raised serious ethical and professional concerns, for example GPs, Clinical Commissioning Groups and hospital trusts making resuscitation decisions without first speaking to residents, families and care home staff or trying to enact 'blanket' 'do not resuscitate' decisions for whole groups of people.

Dr Crystal Oldman CBE, the QNI's Chief Executive commented:

"The care being delivered in a home can at times be as intensive as in a hospital - in particular for end of life care - and it is hugely skilled work. As the majority of respondents to this survey indicate, the people living in their care homes need a combination of support for complex physical and cognitive needs.

"Overall, as would be expected, the picture presented is of an extremely stressful and anxious period for professionals working to care for and protect their residents. The positives represent a silver lining to this cloud and there are numerous testaments to the skill, dedication, professionalism and teamwork that Care Home Nurses have displayed in 2020. In addition, this brief insight into the experiences of the nurses provides an opportunity to consider and plan for the support systems that may be needed in the anticipated second wave of Covid-19.

"More needs to be done to understand the effect of Covid-19 on the workforce and residents in care homes. Urgent attention must be paid to the sector if the workforce is to withstand the additional demands of the pandemic, particularly in planning, guidance and employment practices."

Dr Crystal Oldman CBE, the QNI's Chief Executive

Professor Alison Leary MBE, Director of the ICNO and Professor of Healthcare and Workforce Modelling at London South Bank University commented:

"It is clear from this survey that the care home workforce has faced very challenging issues. Many have felt unsupported and their wellbeing has suffered. We need to support this workforce to face the challenges ahead."

Professor Alison Leary MBE, Director of the ICNO and Professor of Healthcare and Workforce Modelling at London South Bank University

Key findings of the survey include:

70% (114) of respondents were Registered Nurses (RN) and 28% (46) were managers. 78% of respondents were over the age of 45 (128).

Most respondents reported caring for older people (97, 60%) with just under a third reporting caring for a mixture of residents of different ages and needs (48, 29%).

66% (107, 66%) of respondents reported always having appropriate PPE while 2 (2, 1%) of respondents reported never having access to the appropriate type and quantity of PPE during the first three months of the pandemic (March-May 2020). 75% (123, 75%) reported that their employer had provided all their PPE.

During March and April 2020, 34 (21%) reported receiving residents from the hospital sector who had tested positive for Covid-19 in hospital.

70 respondents (43%) reported receiving residents from the hospital with an unknown Covid-19 status during March and April 2020.

54% in total of respondents reported it was easy or somewhat easy to access hospital care with 25% in total reporting it somewhat difficult or very difficult during March-May 2020

In terms of accessing GPs, 67% reported it was easy or somewhat easy to access GP services with 32% reporting it somewhat difficult or very difficult.

23% reported it was easy or somewhat easy to access District Nursing services with 33% reporting it somewhat difficult or very difficult during March to May 2020.

71% reported it was easy or somewhat easy to access end of life medication/services for residents who required it, with 12% reporting it difficult or very difficult.

When asked if arrangements had changed in terms of decision making around do not attempt cardiopulmonary resuscitation (DNACPR), the majority responded "no" (95) that there had been no changes. Five respondents stated they had made no changes to practice as continuous review was normal practice.

16 respondents reported negative changes which they found challenging such as "blanket DNACPR" decisions, or decisions taken about resuscitation status by others (GPs, hospital staff or clinical commissioning groups) without discussion with residents, families or care home staff or that they disagreed with some of the decisions on legal, professional or ethical grounds.

39 respondents reported Covid19 as a positive focus for change in talking about end of life care and a discussion of practice or ceiling of care, for example, moving to a recommended summary plan for emergency care and treatment (RESPECT) process or a reason to initiate conversations around dying and residents' wishes.

Around 20% of responses reported positive or mixed sentiment around the experience of working through Covid-19, for example pride in their colleagues or new workforce opportunities. 80% of responses reported very negative experiences.

56% felt worse or much worse in terms of their physical and mental wellbeing, while 36% reported no change.

Only 62 respondents stated that they could take time off with full pay, while some felt pressure not to take time off at all (15).

ENDS Notes to Editors
The Queen's Nursing Institute (QNI) is the world's oldest nursing charity, having been founded in 1887 to organise the training and supply of District Nurses. Today it offers a wide range of support to all nurses working in community settings in England, Wales and Northern Ireland, and its Queen's Nurses are leaders and role models of outstanding patient care.

The survey was designed by the QNI's International Community Nursing Observatory (ICNO). The survey was distributed online using SurveyMonkey via the QNI Care Home Nurse Network (n~400 members). Members of the Care Home Nurse network range from staff delivering care directly to residents, to leaders overseeing several homes. There were a total of 163 responses to the survey, none were excluded and all 163 answers were available for analysis. There were 21 questions in the survey. The results were collated and analysed using descriptive statistics and sentiment analysis/content analysis from free text. Sentiment analysis was performed using RapidMiner.

More information about the Care Home Nurses Network can be found on the QNI's website: www.qni.org.uk/nursing-in-the-community/care-home-nurses-network
Media Contact:
Matthew Bradby

Head of Communications
Matthew.bradby@qni.org.uk
07985 169471

@mattbradby

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Major New Survey of Care Home Leaders Confirms Severe Impact of Covid-19 - The Queen's Nursing Institute

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The QNI has published a major new report on the effect of the Covid-19 pandemic on the UK's nursing and residential homes.

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This is an evidence-based practice manual for use by all those involved in care provision in England. It should be adopted as mandatory guidance in NHS settings or settings where NHS services are delivered, and the principles should be applied in all care settings.

Introduction

The UK Antimicrobial five-year national action plan, published in January 2019 stated that the Scottish national infection prevention and control manual (NIPCM) will be adopted in England as national standards, to be measured by the regulators.

The NIPCM has been adapted for use within England to support and facilitate healthcare providers to demonstrate compliance with the ten criteria of the 'Health and Social Care Act 2008, Code of practice on the prevention and control of infections and related guidance (hereafter referred to as The " Code of Practice").

Aims

The NIPCM has been produced to:

provide an evidence-based practice manual for use by all those involved in care provision in England and should be adopted as guidance in NHS settings or settings where NHS services are delivered and the principles should be applied in all care settings.

ensure a consistent UK wide approach to infection prevention and control, however some operational and organisational details may differ across the nations.

In all non-NHS care settings, to support with health and social care integration, the content of this manual is considered best practice. The manual aims to:

make it easy for care staff to apply effective infection prevention and control precautions

reduce variation and optimise infection prevention and control practices across care settings in England

improve the application of knowledge and skills in infection prevention and control

help reduce the risk of Healthcare Associated Infection (HCAI)

help with alignment of practice, education, monitoring, quality improvement and scrutiny.

Pathogen specific guidance is out of remit of the NIPCM, which is not pathogen-specific. Pathogen-specific guidance appropriate to England, is produced by other agencies, for example, UK Health Security Agency (UKHSA), and can be found in the A-Z of pathogens resource. The NIPCM outlines evidence-based standards and transmission-based infection and prevention mitigations. The literature reviews that underpin and inform the practical application of the NIPCM and highlight implications for research are available via the NIPCM Scotland website.

Audience and target groups

This manual is guidance for the NHS and as such should be applied by all NHS staff involved in patient care. Furthermore, the principles in this manual should be applied across all care settings (including acute, community and social care), complementing specific guidance produced for these settings.

Scope

Guidance contained within this manual relates to infection prevention and control practice with a primary focus on healthcare (NHS) settings, however, the principles set out are relevant to all settings where care is delivered. This manual is complemented by setting and organism specific guidance, produced by agencies such as UKHSA, and links to other relevant guidance and legislation are provided for reference.

Responsibilities for the content of this manual

NHS England will ensure that there is appropriate consultation with key stakeholders, to ensure that the NIPCM recommendations are appropriate to the system and aligned with the relevant pathogen specific guidance, legislation, and mandatory requirements for England.

Responsibilities for adopting and implementing this manual

All registered care providers must demonstrate compliance with the Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance which outlines ten criteria which care organisations must demonstrate compliance against.

Responsibilities of organisation by role
Chief executives/executive board (or equivalent) are responsible for ensuring:

systems and resources available to implement and monitor compliance with infection prevention and control (Criteria 1, Code of Practice) as specified in this guidance in all care areas; compliance monitoring includes all staff (permanent, agency and, where required, external contractors)

there is a culture that promotes incident reporting, including near misses, while focusing on improving systemic failures and encouraging safe working practices, that is, that any workplace risk(s) are mitigated maximally for everyone. This may entail local risk assessments based on the measures as prioritised in the hierarchy of controls in the context of managing infectious agents*.

safe systems of work, including managing the risk associated with infectious agents through the completion of risk assessments (outlined in Control of Substances Hazardous to Health (COSSH) regulations) and approved through local governance procedures, for example integrated care system level. This is for the protection of all healthcare workers, patients, and visitors. This national guidance outlines the recommended principles to support local decision making within individual organisations.

*Guidance on the hierarchy of controls (HoC) is under development using the defined NIPCM methodology and will be included in the NIPCM content as a priority. Setting-specific risk assessment tools are available to support organisations in applying the HoC.

Chief Operating Officers (COOs) are responsible for:

directing the conduct of operational activities in relation to this guidance

providing leadership, support, direction and assistance.

Directors of infection prevention and control (DIPC) are responsible for ensuring:

adoption and implementation of this guidance in accordance with local governance processes

a workforce that is competent in infection prevention and control practice; (Criteria 6, Health and Social Care Act Code of Practice).

Managers/employers of all services must ensure that staff:

are aware of and have access to this guidance, including the measures required to protect themselves and their employees from infection risk

have had instruction/education on infection prevention and control by attending events and/or completing training; (Criteria 1 and 9, Health and Social Care Act Code of Practice)

have adequate support and resources to implement, monitor and take corrective action to comply with this guidance; and a risk assessment is undertaken and approved through local governance procedures

who may be at high risk of complications from infection (including pregnancy) have an individual risk assessment

who have had an occupational exposure are referred promptly to the relevant agency, eg GP, occupational health or accident and emergency, and understand immediate actions eg first aid, following an occupational exposure including process for reporting (refer to section 1.10)

have had the required health checks, immunisations and clearance undertaken by a competent advisor (including those undertaking exposure prone procedures (EPPs); (Criteria 10, Health and Social Care Act Code of Practice)

include infection prevention and control as an objective in their personal development plans (or equivalent) (Criteria 6, Health and Social Care Act Code of Practice)

refer to infection prevention and control in all job descriptions.

Staff providing care must:

show their understanding by applying the infection prevention and control principles in this guidance

maintain competence, skills and knowledge in infection prevention and control by attending education events and/or completing training

communicate the infection prevention and control practices to be carried out by colleagues, those being cared for, relatives and visitors, without breaching confidentiality

have up-to-date occupational immunisations, health checks and clearance requirements as appropriate

report to line managers, document and action any deficits in knowledge, resources, equipment and facilities or incidents that may result in transmitting infection including near misses, eg PPE failures

apply the principles of good practice for uniform and workwear as set out in the NHS England uniforms and workwear guidance, eg, bare below the elbow

not provide care while at risk of transmitting infectious agents to others; if in doubt, they must consult their line manager, occupational health department, and or their infection prevention and control team (IPCT)

inform the IPCT and local UKHSA health protection team of any outbreaks or serious incident relating to an outbreak in a timely manner and in accordance with local policies and procedures.

Infection prevention and control teams must:

engage with staff to develop systems and processes that lead to sustainable and reliable improvements in applying infection prevention and control practices

have suitably qualified infection prevention and control staff who can provide expert advice on applying infection prevention and control in all care settings and on individual risk assessments, ensuring action is taken as required

must maintain competence, knowledge and skills in infection prevention and control practices

have epidemiological/surveillance systems capable of distinguishing patient case(s) requiring investigation and control.

When an organisation eg, an NHS trust, uses products or adopts practices that differ from those stated in this manual, it is responsible for ensuring safe systems of work, including the completion of a risk assessment approved through local governance procedures.

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National infection prevention and control manual (NIPCM) for England

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This is an evidence-based practice manual for use by all those involved in care provision in England. It should be adopted as mandatory guidance in NHS settings or settings where NHS services are delivered, and the principles should be applied in all care settings.