Unspoken of — domiciliary care in pandemic times
The world of residential, nursing and domiciliary care is about as unsexy as it gets. Rarely are there headlines around poorly-paid workers entering homes and residential rooms of the elderly to change a catheter and give them a wash, and generally encourage them to get through an often-lonely day as cheerily as they can.
These are, as is oft repeated, not normal times. And as is the case with COVID-19 more generally, the attention on the social care sector are reflections of urgent times. The scale of excess deaths in care homes has been horrific. We already know that residential and nursing care is very much going to be a last home for the residents (and they are not, Robert Peston, ‘inmates’ — their lives are stigmatised enough without that kind of label being applied).
And we know full well that social care is an area where infectious diseases can thrive. Infection control is difficult, guidance is lacking, and there is the added caveat that these are people’s homes, not a hospital ward which is set up with spread of infections in mind. This includes flu, norovirus and my own particular fascination, the icky itchy subject of scabies. Scabies is a Neglected Tropical Disease, yet highly prevalent in UK institutions. If you feel so inclined, you can read more about our study in English care homes, or the problems of bad science in scaring off use of an effective scabies treatment.
I digress. There has now been some belated level of attention on care homes. The focus of this blog is specifically domiciliary care. The kind of job when a care worker visits a person’s home, rather than when the resident moving into a care home. The minimal pre- and during-pandemic focus has resulted in huge uncertainty across the sector about good practice when entering people’s homes.
Here follows an anonymous voice, adapted by me with permission, but originally written by a domiciliary care worker in the southeast of England. Italic text are their words.
“Let me begin by explaining the way domiciliary carers would normally conduct a typical visit. Either one, or two, carers will enter a customer’s house. They will be carrying two essential items of equipment. The first is a smartphone loaded by the agency with an app. This is the principal vehicle of confidential communication between each carer and the agency managers located at a central office. The entry for each visit contains a list of ‘tasks’ for the visit. Carers should type in a brief note (often a word or two) to demonstrate they have finished the tasks. The second item of equipment is the carer’s PPE (personal protective equipment), in normal circumstances, gloves and an apron. Where gloves are sullied in the course of intimate care, they will generally be changed, if the carers are not in too much of a hurry!
Typically, the carer will first tag in using their smartphone; then don their apron and gloves. Normally towards the end of the call, they will begin to ‘do the notes’ using the smartphone. They may or may not remove gloves in order to do this. Finally, carers will remove PPE then tag out, or tag out then remove PPE, and leave the property. “
That’s how domiciliary care typically works. How should typical practice change during the pandemic? By the middle of March, when the rates of infection were beginning to look worrying, there was little guidance from the agency other than iterations of the familiar government advice to ‘wash hands’.
“I therefore updated my own routine as best I could, for example heading straight for the bathroom or kitchen without touching doors or walls, washing my hands and if possible using disposable paper towels to dry my hands. This reduces contamination from outside (my person, my car, the client’s door handle). I extract my smartphone from my pocket and tag in, replacing the smartphone in my pocket, and don apron and gloves [note from blog author — no masks]. I try not to change my gloves if I can. Every glove change risks contamination, unless accompanied by hand-washing which is time-consuming, I leave the ‘notes’ as far as possible to the extreme end of the call to reduce repeated handling of phone. Then, I remove apron and gloves, wash my hands thoroughly, take smartphone from pocket and do notes. This avoids touching phone with contaminated hands. Finally, I tag out, replace smartphone in pocket and leave without touching anything. This then has become my regular routine.”
Then came the official advice from company management. With the pandemic worsening, domiciliary carers have been subjected to a growing stream of directives from the management on the maintenance of personal hygiene. From our anonymous voice —
“‘Then the official messages started to be sent out from the agency, for example
- Full PPE should always be donned before entering a customer’s house. (This instruction has been given particularly prominence by being placed at the head of the ‘general notices’ that come up whenever carers enter the app). How does this prevent contamination being brought in from outside (carer’s person, car, customer’s doorbell and door handle)?
- Care should be taken to change gloves frequently in the course of the call, wherever the succession of tasks seems to require it. Surely every glove change presents an additional risk? Unless, that is, each change is accompanied by handwashing. This would be excessively time-consuming, and effectively impossible — especially given the fact that gloves can only be put on when hands are thoroughly dry. I would have thought the Covid infection risk would be a reason to reduce rather than multiply glove changes.
- In doffing their PPE, carers should wash their hands thoroughly between removal of apron, and removal of mask, between removal of mask, and taking off gloves, then once again, a third time, on removing gloves. This is a level of protection more suited to caring for infected patients in ICU. In the context of half-hour domiciliary care calls, it is ludicrously over-complicated and time-consuming.
- Smartphones can be washed using soapy water. On every call? Smartphones are generally protected by a corrugated plastic case that cannot easily be washed.
These instructions were largely in contradiction with the routine I had imposed on myself some weeks before. Of course, I am no expert in infection control. In principle, I would be more than happy to change the routine I had devised for myself for a better informed one supplied by the managers of my agency. However, the avalanche of messages coming down from the management (of which I have given a sample above) strike me as not adding up to a consistent alternative. In fact, they are, in some cases, contradictory and/or quite impractical.
Our anonymous voice continued that, in the case of their colleagues, their reaction has been to ignore these instructions entirely. They simply continue to do what they have always done — perhaps with a bit more assiduity when it comes to the wearing of PPE. To quote —
“Needless to say, hands are never washed; indeed, it has never been made clear, given the universal wearing of gloves, in what circumstances hands SHOULD be washed. Personally, I can sympathize with this reaction. That said, it seems rather a shame. After all, there are probably better and worse ways for a domiciliary carer to enter a customer’s house without infecting it with Covid19.”
It’s rather difficult to know the extent of any transmission around domiciliary care. For example, we have care homes stats. But this involves people in the community rather than any particular institution, and thus an infection would end up in the routine primary care or hospital statistics rather than a tick in any ‘domiciliary care’ box.
Policy and practice are two different beasts. In these unusual times, it is even more important that policy indicates best practice. However, spot checks are difficult or missing altogether, and pandemic practice in domiciliary care is very much an unknown. There are issues around use and provision of masks. Asymptomatic or pre-symptomatic transmission is an issue, particularly with the return of some children to schools on 1 June, and potential household transmission where the care worker has school-age children. This is all a tricky mix of high-level stakeholders, including different private providers, local authorities, and the NHS. Collaborations are tricky.
It’s not sexy. It’ll never get the headlines of a clinical trial for a new COVID-19 vaccine. But there’s knowledge gaps aplenty around a sector of a vulnerable group of people, who need and deserve wider attention than they have at the moment.
