COVID-19 guide for drug and alcohol residential rehab and detox services

Living and working with COVID-19

Published: July 2020

What is a residential rehabilitation or detoxification service?

Residential rehabilitation services and detoxification services for people tackling drug and alcohol dependence operate very differently from traditional care settings. They are classified as healthcare services by the Care Quality Commission (CQC), and people’s stays in them are generally time-limited, and based around a planned programme of treatment and/or rehabilitation from addiction. While detox and rehab settings face many of the same challenges as more typical care settings, the expectations and ways of working in traditional care homes that relate to the COVID-19 pandemic – for example 14 days’ isolation for new residents - can cause real problems to people’s treatment programmes, and can heighten the risks of detox or rehab not working. The health risks for people using detox or rehab centres can be particularly acute and severe if treatment is not effective, and so the risks from COVID-19 have to be carefully balanced against other health risks people may face, including any risks to people’s mental health.

This guide, produced with the close involvement of Public Health England, residential services, and their membership bodies in the sector, aims to provide specific and useful information for all residential detox and rehab services dealing with COVID-19. It looks at various aspects of life and work in residential detox and rehab settings, and works on the presumption that at least some impacts of the pandemic will continue for some time to come, and therefore the sector will need to make lasting adjustments to some practices and procedures.

Admissions and isolation periods

Having clear but proportionate pre-admission and admission processes is a vital element in managing detox or rehab settings in a way that minimises the risks of COVID-19. Government guidance is that all new admissions to care homes must be isolated for 14 days to reduce any spreading of the coronavirus. This guidance does not indicate whether it is intended to apply to the rehab/detox sector.

Some rehab programmes last as little as four weeks; most last no more than 12 and some detox programmes last 7–10 days. This can make a two-week isolation period for detox and rehab treatment inappropriate, as it makes accessing group sessions difficult, and can also make 1:1 interactions problematic. People entering detox or rehab are typically anxious about the experience, and making connections with other people experiencing similar challenges not only helps with this, but is a vital part of their treatment. Such connections are harder if a fortnight’s isolation is required.

Some settings, therefore, are shortening the isolation period, usually on the basis of a negative COVID-19 test upon admission, and again after five days. This is counter to government guidance for care homes, but may often be proportionate for the rehab/detox sector, regulated differently as it is. Services have to make their own assessments and reach judgements for each individual, based on what is best for the resident, and the home as a whole. Examples of the sort of issues to be considered include:

  • Pre-admission risk assessment – do you know if the newly admitted person has been able to effectively isolate before coming into the home?
  • Vulnerability of the wider home – are there any residents who are in higher risk groups?
  • Individual mental health – is there a risk that prolonged isolation may make the resident leave early, thus increasing their risk of relapse?
  • In mother and child settings – what are the potential safeguarding concerns resulting from prolonged isolation?

If this approach is to be adopted, it should be supported by careful risk assessment and management, and discussed with commissioners and the Care Quality Commission.

With careful planning, involving the newly admitted person, many of the problems with the isolation period – even up to 14 days – can be lessened. There are useful steps that services can take which minimise the risk of COVID-19 infections from new admissions, while allowing for good rehabilitation and treatment to start as soon as possible:

  • Incorporating the 14-day period into the treatment programme, as a COVID-safe introduction to treatment.
  • Working with the individual to explain, gain consent for, and personalise any isolation – or welcome – plans and processes that you have. It will be important for gaining buy-in to any treatment programme that the person understands what limitations there may be due to isolation, and how these might be mitigated. Discuss, for example, how 1:1 therapies will be conducted during the initial days of isolation, or how group support can be accessed via video conferencing.
  • Some homes may be able to access tests, although, at the time of writing, they are not included in the government’s care home testing inclusion criteria. This would allow units to test new admissions in line with other care homes and decide whether to continue isolating someone who tested negative and displayed no symptoms. Some homes require two negative tests before considering shortening the period of isolation, because any negative test needs to be treated with a certain element of caution.
  • Use pre-admission screening tools. Clearly these lack the relative assurance of a test, but asking people prior to admission about symptoms and recent contacts with people will help inform any risk assessment upon admission.
  • Administering any physical/biological tests – such as a breath alcohol level test or urine screening – in line with social distancing and infection control guidelines.
  • Adapting standard risk assessment and management plans to include specific consideration of COVID-19. Risk mitigations could include:
    • Staff wearing full personal protective equipment (PPE) while working with all new admissions, as if they were COVID-positive.
    • Ensuring the same PPE is not used when supporting different residents, wherever possible.
    • Isolating people in ensuite rooms, if possible, so that bathrooms and bedrooms do not need to be shared. In some settings, it may be possible to have separate isolation units for new admissions. Some settings are calling these welcome units to avoid the negative connotations of isolation.
    • Conducting twice daily health checks, including temperature testing, to check for signs and symptoms of the coronavirus.
    • Providing all meals and medicines at the room door, while making an extra effort to make the meals appealing, such as providing personal favourites to people.
  • Encouraging, and planning for, solo entertainment during the isolation/welcome period – books, music, mobile phones, games consoles and so on.
  • Having a structured plan for each day with mix of therapeutic activity, social time, and structured meal times.
  • Accessing online mutual aid groups during any initial period of isolation. Some people may not be confident with this, and may need staff support.
  • Giving particular thought to the support needs of people in mother and child units.
  • Registering the new arrival with a GP as soon as possible. Different services have different guidelines on this, but you should certainly aim to register a new resident within 48 hours of arrival.
  • Gathering information from the person’s previous GP, other professionals, and their family as appropriate, and with the newly arrived person’s consent, so that a full picture of their needs can be gathered.

Some homes have a blanket exclusion of new admissions where the person is displaying COVID-19 symptoms, or a policy of delaying admissions until symptoms have passed. Other homes are taking symptomatic people, ensuring they are carefully supported and isolated. Each individual should be assessed separately, bearing in mind the person’s needs, and the ability of each different setting to support them safely and effectively.

If the new arrival shows symptoms of COVID-19 (a new, persistent dry cough; a high temperature; a loss or change to your sense of smell or taste), then they should be isolated and supported in the same way as other symptomatic residents – see below.

Testing

The drug and alcohol detox and rehab sector has not, at the time of writing, been prioritised as part of the Government’s roll-out of whole-home testing. Until it is, providers may be able to access tests through other routes. If a unit can test residents on admission, then a negative test, coupled with there being no symptoms, might allow for a shortened period of isolation, and a positive test would allow for strict isolation measures to be targeted at the right people.

The other important part of the equation is testing for staff. Staff can apply for tests utilising the essential worker self-referral service or according to local testing policy. If a staff member becomes symptomatic and/or receives a positive test, they should self-isolate, keep in contact with their line manager via phone and agree contact arrangements for when they recover from the virus. This might include a period of working from home, and staying connected through virtual team meetings and the like, if that is possible/useful before a full return to work.

Using the NHS Track and Trace service, homes will need to prepare for staff being isolated at home at short notice.

Aside from antigen tests, homes can also employ daily checks including temperature testing, and checks for signs and symptoms of COVID-19.

Social distancing for residential rehab or detox services

Social distancing within units is difficult. The sector appears to be taking two broad approaches to the question of socially distancing asymptomatic residents:

  • Treating the whole unit as one large household by accepting there will be no social distancing between residents, and focusing instead on social distancing between relatives and staff.
  • Breaking the unit down into smaller clusters of residents, and maintaining social distancing between the different clusters, as well as between them and staff.

Which of these options is adopted will depend in large part on the size, physical layout and demographics of the unit in question; a cluster approach will simply not be feasible in every home, although it may be preferable in terms of managing any cases of COVID-19, and subsequent self-isolation for people who have been in close contact with the ill person. Homes where children are staying will have particular challenges in this regard, and will need to be additionally vigilant in applying other risk mitigation processes.

Whatever the approach, there are some simple measures that homes are adopting to minimise the risk of spreading the coronavirus:

  • Reviewing the use of specific rooms, such as offices and therapeutic rooms, for maximum flexibility.
  • Reconfiguring dining rooms, so that chairs are spaced further apart. This may require meal times to be staggered.
  • During meal preparation, having separate work stations within the kitchen to maintain a two-metre distance.
  • Setting chairs further apart during group counselling sessions. In some homes, this has resulted in smaller group sessions.
  • Maintaining social distancing during 1:1 therapy/counselling sessions. Some settings are using tape to mark out safe distances and safe areas.
  • Maximising the use of outdoor space.
  • Reminders – on posters, and in person – of the importance of maintaining safe distances between people.
  • Reminders for people going out into the community about maintaining social distancing, and wearing face masks where necessary.
  • Requiring people returning from a trip out to wash their hands, and for handwashing to become a regular activity throughout the day.

Self-isolation

  • For people with COVID-19 or symptoms Open

    Once someone appears to have, or is confirmed as having, COVID-19, social distancing and infection control measures should be more stringent. What is possible will, again, depend on the physical layout of the home, but should, where practicable, include:

    • A 14-day isolation period in a single room, with a bathroom, or isolation in another self-contained area.
    • PPE to be worn by staff when in contact at the room door with symptomatic residents. If the task is simply to hand over food or medication, it is likely that a mask and gloves will be enough. If more intimate support is provided, full PPE, including aprons and visors, may be necessary.
    • Masks to be worn by symptomatic residents when in contact with other people. Residents with respiratory conditions may need additional support to manage this.
    • All meals and medications to be provided at the room door. Some units are stopping the use of medication rooms, and administering all medication in individual rooms, to reduce the gathering of residents in one place.
    • A risk assessment should be undertaken to establish the nature and duration of exposure and contact with other residents and with staff.
    • The person’s GP to be informed (and other professionals and family if appropriate), and a request made for testing for COVID-19 (if the case is not yet confirmed). The test should be accessed through the NHS portal or local access point.
    • Systematic health checks throughout the day for other residents and staff.
    • Support to keep people engaged and entertained during isolation: in-room activity packs, books, electronic equipment and so on.

    For further advice and guidance, refer to the service’s GP or call 111. In an emergency, dial 999 and inform the call handler that the unwell person may have COVID-19. Prepare a bag with health information, a medication list, and family contact information in case a person needs to go to hospital.

    If an outbreak – two linked cases of COVID-19 – is suspected within the home, contact the local Health Protection Team.

  • For people exposed to symptomatic residents Open

    Other residents who are identified as being at risk of COVID-19 due to the contact they have had with a symptomatic resident should be supported proportionately, in line with advice from the NHS Test and Trace service. Measures should be put in place to reduce any potential risks: everyone in the cohort to have their own bedrooms and bathrooms; all support to be delivered by staff wearing masks and gloves, or fuller PPE if close-contact personal care tasks are being carried out; regular health checks etc. If a resident become symptomatic during the period in which they are isolating following a test and trace contact, they should self-isolate as per the guidance for symptomatic residents above.

Shielding in drug and alcohol residential rehab and detox services

All residents who fall within the ‘clinically extremely vulnerable’ category will need additional support measures. Government guidance on supporting this cohort of people is changing, and homes will need to track the alterations, and adjust processes accordingly.

Homes will also be aware of people who have additional needs, who may or may not fall within official government guidance. It is advisable to ask all new and existing residents to complete a questionnaire detailing pre-existing conditions, and from there to compile a list of all residents who will need extra care and support in avoiding COVID-19. Communicate closely and carefully with vulnerable residents so that they feel in control, and understand any risks.

Liaise with GPs and other supporting health professionals to review people’s individual health needs, and to plan their support and treatment programme within the context of the shielding.

Even as the Government eases restrictions for the more vulnerable cohorts of people, it is advisable to maintain and update individual risk assessments, and to maintain core measures to minimise the risks of COVID-19. Depending on individual circumstances and risk assessments, these may include:

  • staying in single rooms
  • staff to wear PPE equipment for all contact
  • minimising interactions wherever possible
  • facilitate access to adequate medications and GP phone appointments
  • daily health checks, including temperature testing.

Where residents are identified as needing to shield, but then choose not to do so, organisational policies will need to be used to frame a response to this.

Infection control

Practising good infection control is an important part of preventing the spread of COVID-19. Rehab units especially, however, are rarely set up as clinical environments, with a focus instead on comfort. This can make infection control a little more difficult, but there are proportionate measures which can help:

  • Increase cleaning practices across the whole service, focusing on shared surfaces, door handles and other areas which are touched frequently.
  • Where possible, use single-use equipment, and dispose of them after use. Where single use is not possible, use dedicated equipment in the individual’s room. This should not be shared with other individuals receiving care. If it is not possible to dedicate pieces of equipment to the individual, items must be decontaminated immediately after use, and before use with any other individual.
  • Do not use fans, which re-circulate the air. Instead, open windows for ventilation if it is safe to do so.
  • Try to keep residents’ rooms clutter-free, and avoid storing any unnecessary equipment or soft furnishings in individuals' own rooms to prevent unnecessary contamination of items
  • If a resident is symptomatic, then any waste from them (e.g. used tissues) should be placed in clinical waste and disposed of immediately. If the service does not have a clinical waste contract, ensure all waste items that have been in contact with the individual are disposed of securely within disposable bags. When full, the plastic bag should then be placed in a second bin bag and tied. These bags should be stored in a secure location for 72 hours before being put out for collection.
  • Any, towels, bedding or other laundry used by a symptomatic resident should be treated as infectious, and placed in a bag before removing from their room and washed.
  • Follow an appropriate COVID-19 cleaning protocol after a room is vacated by someone who has been confirmed as having the virus, and in any case make sure that whenever a room is vacated, it is cleaned thoroughly before further use.

It is important that all settings realise that enhanced hygiene around the home should become the default way of working from here on. Improved infection control will be a long-term aspect of living and working alongside COVID-19.

A basic but important element of infection control is good handwashing. This is the case both for staff, and for residents. Health and Care Innovations have created a useful video. Good respiratory hygiene when coughing, sneezing, or blowing your nose is also key.

Personal protective equipment (PPE)

Residential rehab and detox providers must carry out a full risk assessment for their staff, and provide them with the personal protective equipment (PPE) (gowns/aprons, masks, gloves, etc) that may be required, and training in how to use the PPE. Weekly audits of PPE supplies can be helpful in ensuring an adequate supply.

People working in rehab settings should wear the following PPE when in close contact with the person being supported, whether or not the person has COVID-19 symptoms:

  • disposable gloves
  • disposable plastic apron
  • fluid-resistant surgical mask (FRSM)
  • eye protection coverings – these will be subject to a risk assessment, depending on the individual case.

Staff should also wear a mask when working in communal areas, or performing tasks within two metres of people. Disposable gloves, aprons, and eye protection would not usually be required in this situation.

Grab kits for emergency health situations should now include PPE.

Public Health England provide full guidance on the use of PPE and working safely during the COVID-19 outbreak for workers in care homes.

Staff should also be trained in donning and doffing (putting on and taking off) PPE. Public Health England have produced a video guide to using PPE in care homes, which may be helpful. Having posters on display in staff rooms can also be helpful.

If there are problems accessing PPE from usual suppliers, first try recommended wholesalers, then the local resilience forum or, if about to run out, contact the dedicated helpline for an emergency supply of PPE:

Visitors and social contact

Since the start of the COVID-19 pandemic, residential rehab homes and detox units that normally allow visitors have, like other care homes, not been open to visitors. All family contact, therefore, has been via video conferencing or other remote contact, and restrictions on visitors are likely to be a feature of detox and rehab settings for the foreseeable future.

Opening up detox and rehab settings to visitors to some degree will need to be guided by governmental regulations, and careful risk assessment. Factors to consider in risk assessments would include:

  • The opportunity for visits to take place outside. Homes are experimenting with visits in gardens, using gazebos, Perspex screens etc. to facilitate contact.
  • The number of visitors – any equipment used to facilitate contact, such as garden chairs, would need to be disinfected after each use, so it is likely that the number of visitors on any given day would need to be limited.
  • The suitability and acceptability of video conferencing or other remote contact. If everyone involved is happy with video or telephone calls, then the additional risks of visiting in person may not be justifiable.
  • Requirements for visitors. Visitors could be required to complete health questionnaires, wear masks, wash their hands upon arrival, and have their temperature taken, for example, to lessen the risk of transmission of COVID-19. Many homes are applying these requirements to all visitors, including contractors.

Further reading

Support from SCIE

SCIE's COVID-19 hub contains more relevant information including safeguarding, Mental Capacity Act and infection control. It can be used when working and supporting people who are isolated or vulnerable through COVID-19, and can also be shared with community groups.