Covid-19 Risk Assessment

Preamble / Rationale

On the 5th May 2023, the World Health Organisation (WHO) announced the lifting of the Public Health Emergency of International Concern (PHEIC) status on Covid-19, signalling the start of a new phase of response and recovery, while emphasising that the pandemic has not ended, and remains a global health threat.

Since the rollout of vaccination, and the advent of the Omicron variant, most people infected with Sars-Cov-2 are either asymptomatic (estimates 40-60%) or have only mild symptoms (often similar to a cold) in the initial acute phase. 

However, the UK government, for this winter, drastically scaled back eligibility for the vaccination programme which has played such a crucial role in reducing the severity of infections, and in 2024 plans to reduce it even further.

People are still dying from Covid, it is just not being reported by the media anymore, and the ONS data is not easy to find or interpret. For example, I am writing this on 22 / 02 / 2024 and in the first 6 weeks of this year, there have been 1,976 registered Covid deaths in England, 137 in Wales, 221 in Scotland, and 101 in Northern Ireland, making a total of 2,435 people, or 405 people a week. Yet most people are totally unaware of this. 

Moreover, what affects far more people, is the very common ongoing health consequences, after the acute phase. There is now a huge body of evidence on this, I am just going to refer to a couple of sources. 

'Long Covid': At Least 1 in 10 Infections

Long COVID: major findings, mechanisms and recommendations, a review published over a year ago, on 13/1/2023: 

"Long COVID (sometimes referred to as ‘post-acute sequelae of COVID-19’) is a multisystemic condition comprising often severe symptoms that follow a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. At least 65 million individuals around the world have long COVID, based on a conservative estimated incidence of 10% of infected people and more than 651 million documented COVID-19 cases worldwide 1; the number is likely much higher due to many undocumented cases. 

 

The incidence is estimated at 10–30% of non-hospitalized cases, 50–70% of hospitalized cases 2,3 and 10–12% of vaccinated cases 4,5. Long COVID is associated with all ages and acute phase disease severities, with the highest percentage of diagnoses between the ages of 36 and 50 years, and most long COVID cases are in non-hospitalized patients with a mild acute illness 6, as this population represents the majority of overall COVID-19 cases.

Hundreds of biomedical findings have been documented, with many patients experiencing dozens of symptoms across multiple organ systems 7 (Fig. 1). Long COVID encompasses multiple adverse outcomes, with common new-onset conditions including cardiovascular, thrombotic and cerebrovascular disease 8, type 2 diabetes 9, myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) 10,11 and dysautonomia, especially postural orthostatic tachycardia syndrome (POTS) 12 (Fig. 2). 

 

Symptoms can last for years 13, and particularly in cases of new-onset ME/CFS and dysautonomia are expected to be lifelong 14. With significant proportions of individuals with long COVID unable to return to work 7, the scale of newly disabled individuals is contributing to labour shortages 15. There are currently no validated effective treatments."

Damaged Immunity

There is growing evidence that Covid infection damages the immune system, which is why so many people now complain that both themselves and their children get ill more often than they used to, and people have noticed coughs that last for months. 

Increased Health Risks with Every Infection

In one study on the risks of having more than one infection, https://www.nature.com/articles/s41591-022-02051-3 it has been established that those who have had Covid more than once are twice as likely to die and three times more likely to be hospitalised than those who have had it once, 3 1/2 times more likely to develop lung problems, 3 times more likely to develop heart conditions, and 1.6 times more likely to develop brain conditions, across all cohorts. 

There are also many other studies showing increased incidence of both mental and physical health problems of various kinds with Covid infection.  For those in more vulnerable populations, risks are of course higher. 

Therefore, I will continue to keep a high standard of precautions against transmission in my practice for the sake of my self, my family, my clients, and indeed everyone all of us come into contact with. 

Risk Assessment

Date Last Amended: 22/02/2024 by: Ceri Turner

All actions already have been or will be carried out by Ceri Turner, as appropriate.  

Date of Next Review: Check for changes to Government Guidance and Law regularly and update if necessary. Re-read in entirety monthly.

Government Guidance Updates at https://www.gov.uk/guidance/working-safely-during-coronavirus-covid-19/close-contact-services then at https://www.gov.uk/guidance/working-safely-during-covid-19/shops-branches-and-close-contact-services.

Viewing on a desktop? Apologies that the chart is very narrow and the text very small. This is so it is readable on a mobile phone, which the majority of site visitors use. I recommend that instead you view on Google Drive

Viewing on a mobile phone? The chart may be just wider than your screen. Try rotating your phone sideways, and it should then fit on your screen.

Activity and Items	Hazhards & Risk – Who Might be Harmed and How?	Control Measures
1. Booking and Pre-Booking Screening of Clients and Therapist	Booking by a person who should not attend because of their high vulnerability to Covid, or because of post-Covid risk factors of massage.   Attendance at an appointment of an infected client, or an infected therapist, with transmission risk.   Transmission while talking face to face to take booking. Extra time in shared space.   Transmission via Paper to Therapist or to Client by both touching a diary.	An appointment only system. For those who have been hospitalized with Covid-19, it is required to discuss with their GP before booking. Intake forms screen for Post-Covid sequelae, particularly thromboses. Pregnant clients booked with GP or Midwife approval only. All clients are asked to cancel (and if wished reschedule) if they are have a fever, diarrhoea or vomiting, or have a infectious or contagious disease - including flu, Covid, or a cold.  Covid - screening form includes a full, comprehensive and up to date list of Covid symptoms. Clients are also asked: In the past 10 days, have you been at home with, or in close contact with, anyone who has symptoms of COVID-19, or has tested positive for it? Are you required to self-isolate currently according to the NHS Test and Trace service, a Health Professional, local Public Health Officer or Border Control?  Have you had a positive Covid test result within the last 10 days, or are you awaiting the result of a PCR test? An answer 'yes' to any of these questions would require a reschedule. Policy on website and in email to clients from states:  If you have recently had Covid, or may have had (ie you have had "cold" symptoms) please do not attend an appointment until its been 10 days since infection - or if you don't know exactly when you were infected - 10 days since the start of symptoms, or from your first positive test. I will do the same. If you have been in close contact with someone with Covid-19 (or with "cold" symptoms where Covid has not been ruled out), please do not attend an appointment for either 10 days after the last time you had that contact OR for at least 7 full days after that close contact, having had negative LFTs (or PCR) on both day 5 and day 6. If I have any contact with someone with Covid, I will do the same. If you are not sure what should count as close contact, (eg if they tested positive days after you had been in contact with them, so may or may not have been infectious when you saw them) please contact me to discuss it. If I have had a possible contact, I will test every day for at least 7 days and even if testing negative, contact clients booked in that period to give the option to reschedule. Reminder email 24 hours before appointment states "Please now review your forms (in particular the Covid-Screening and Consent Intake Form) to make sure nothing has changed using the 'Edit Forms' button. If you start to experience any COVID-19 symptoms (including a high temperature, a new or continuous cough, or a loss of or change to your sense of taste or smell) or feel at all unwell, including just a cold, please postpone or cancel your appointment!" Cancellation policy so that there is no cancellation fee if client cancels for any reason related to Covid infection control. Therapist self-screens for Covid symptoms, and does regular lateral flow tests. Online booking through Acuity.
2. Taking Payments	Cash is a low transmission risk to therapist and client.	Payment system, through Acuity and Paypal or Stripe, or by Bank Transfer, available. For cash payments, clients are asked to bring correct money and place into a dish. However, change is available. Therapist hands washed after cash handling.
3. Consultation and Form Filling	Transmission while talking face to face. Forms – transmission to client or to therapist by touching same pen or paper, or clipboard or table.	Consultation is conducted at over 2 metres distance, and with client wearing face covering and therapist wearing FFP2 equivalent mask. Remote consultation over videoconferencing or phonecall is available if requested by the client, or suggested by an individual risk assessment, for example, if the client is exempt from wearing a face covering and / or needs a longer consultation. The majority of intake forms done online, by the client. If a client does not have internet or ability to do online forms, these will be sent through the post for them to fill in, sign and return to me by post, though this will delay booking and is not ideal. Then each session will have a summary of agreements to sign with their own pen, or a sanitised pen provided.
4. Client Attendance at Clinic – General.	Contact with therapist, contact with other members of the public, and risk of transmission to or from the client.	Client to arrive as close as possible to appointment time. There are areas of the site that are under cover if the weather is bad, they arrive early, and they do not have a car they can sit in while they wait.
5. Transport - Use of Carpark and White Cross Reception by clients	Transmission risk by client visiting reception – touching door, sharing space with others, touching ipad, pen and log in book, to register for permit.	Clients who will be parking at White Cross, advised to let the therapist know their registration number, and I then email in to gain them a parking permit for the day without them having to visit the Gatehouse Reception. Bike racks are available and mentioned in a flyer about the location and transport given to all clients. There is adequate provision of carparking spaces for the site. Videos explaining how to walk to Holistyx are on my website Location page. Therapist always walks to work.
6. Building – Entry, Exit, Corridors, Doors.	Risk of transmission via shared space, or contact points	The cleaning company, Lancashire County Council Facilities Management, use a cleaning solution which needs little contact to kill viruses. https://www.tersano.com/product-details/iclean-mini/ The cleaners, in addition to the normal daily cleaning, are concentrating on heavily used touch areas and there will be a second clean of areas from 3 pm to 4 pm. Sanitiser is available by both entrances to the building. Therapist will wash or sanitise hands after any touching of doors in the building, on the way in or out.
7. Toilets		Toilets are maintained by the Landlord, which is the County Council, so it is on trust that they will adhere to necessary standards. They have enhanced their cleaning for busy areas. Clients use: Clients are advised by signage that 1 person must enter and use the toilet at any one time to maintain social distancing. There is handwashing guidance displayed in the toilet areas. If a client needs to use the toilet during the session, the therapist will wash hands and open the room door, and the client will be asked to wash their hands again or use sanitising gel, because they will have needed to touch doors on the way back through the building.
8. Entering and Leaving the unit, Waiting Room and Consultation area Seating.	A waiting room increases the amount of time the therapist and client share the air in a semi-enclosed space. Transmission from one client to others or between therapist and clients, by sitting on the same seat in waiting room or consultation area, contacting the same cushion, touching a curtain. Transmission by touch to therapist or to clients (low risk)	No waiting area. Client chair cleaned and sanitized after every use. Soft furnishings minimised. Curtains arranged so clients can walk through to handwashing facilities without touching them, and then to walk through to the couch without touching them, and also to enable therapist to walk between the treatment area and the handwashing and oil blending area without any contact not only with hands but between uniform and curtains. Therapist opens the door at the appointment time. Client instructed in booking forms not to touch anything other than necessary. Furniture and items which the client may touch are clearly situated in their route through the unit to the couch, whilst items which they must avoid touching, situated as far from this route as is possible. No unnecessary items which clients might wish to touch. Clients asked to drink before and after session, in order to avoid removal of face coverings, so there are also no cups or bottles for fomite risk. However clients are now allowed to briefly remove mask to drink from their own bottle if they have brought one, considering the high standard of air filtration in place. Flooring - clients removing shoes on entry to room. Swept as necessary. Hoovered daily, not between clients, to avoid making virus airbourne. In the morning as this lowers the risk from the activity to the person hoovering and to therapist and clients, as most Sars-Cov-2 (if present on the previous day) will likely have dried out and been deactivated.
9. Storage of Clients Belongings	Transmission from one client to other clients from shoes, coat or other belongings touching the same surface, eg Coat rack, shoe rack.	A plastic lidded box, sanitised after use is provided for shoes and outdoor clothing, bag and possessions. Another is provided for clothes in the treatment area.
10. Massage Couch, Linens, Pillows and Bolsters, Equipment and Storage	Cross contamination from client lying on the couch and contacting items on the couch – from breathing, any coughs, sneezes, or dribbling of saliva.	A Waterproof couch cover which goes over the electric couch warmer is cleaned and sanitised after every client. One layer of couch roll to absorb oils may be used for massage clients, and binned after use. All pillows, cushions and bolsters are covered with a waterproof non-porous cover which is sanitised after use. These are usually further covered with clean washable pillowcases or fleece wraps. Any linens (including towels, fleeces, or blankets) used as drapes to cover client or to cover bolsters etc are fresh and clean for each client. Client wears a face covering or mask.
11. Seated Treatments	Cross contamination from client on chair – from breathing, any coughs, sneezes, or dribbling of saliva.	Waterproof, non-porous chair cover, sanitised after use. Bolsters and pillows as above. Positioning of HEPA air filters either side of in front of client. Close enough to be effective, not so close as to annoy by their proximity or noise level.
12. Therapist Hygiene and Protective Wear		Therapist is well, no sign of infection. Good personal hygiene, bare nails, hair tied back if long. Clothes: Clean uniform daily, changed into at work, and changed out of before returning home. Top is a zip and button up tunic, which prevents contamination which might occur from those lifted over the head. Work clothes treated as linens, re laundry protocol for storage and cleaning. If the therapist’s uniform comes into contact with the client, the therapist will change into clean clothing before seeing the next client. Hands: Trained not to touch face during treatment time. Frequent hand washing throughout the day, especially before or after touching the face. Therapist washes hands for at least 20 seconds following NHS protocol, and then also arms thoroughly up to the upper arms, then dries thoroughly using towel, before and directly after treatment. Clean hand towel at least daily. Hands washed or sanitised before putting on and and after removal of mask, gloves, visor, or goggles. Face: A ventilator mask (Cambridge mask - FFP2 equivalent) will be worn by the therapist at all times from before client enters to minimum 10 minutes after they leave. Any coughs or sneezes, towards shoulder, and if there is time, moving away from client towards open window, door, or air filter. The mask will be sprayed by Dew Disinfectant after every use, and washed carefully as needed as per manufacturer instructions. Visor or goggles are added if therapist’s face comes in sustained close proximity to a clients high risk area (ie face and and breathing zone), or if working on client exempt from wearing face covering. Cleaned and sanitised after use. There would only be a risk of contact with bodily fluids in very exceptional circumstances. In those circumstances, gloves would be worn (gloves will also be worn if therapist skin is not intact - eg a cut or graze).
13. Client Hygiene and Protective wear		Massage Advice Leaflet and webpage: “Have a shower or a bath as close to the appointment as you can.” Tissues provided in the Consultation and treatment areas, which can be used if they need to blow their noses, and to then dispose of these in an appropriate bin after use. Hand sanitizer is available nearby in the treatment area. Hands will be washed after leaving the consultation area anyway. Client required to wash hands for 20-30 seconds and dry with small fresh towel before coming to the couch. After the treatment is optional. Client required to wear face covering. If those who are exempt seek treatment, I will discuss if there are accommodations which can be made, for example, a shorter session, remote consultation, prone only, moving the couch near to a wider open back door, or working on a chair near the back door - or advise referral to colleagues who are happy to treat people without face coverings. Depending on a risk assessment both re risk to the client and to the therapist, including the local status of the pandemic at the time. The expectation will be that the face covering will be worn for the entire time the client is in the room. If a client becomes unable to breathe or extremely distressed, eg if there are difficulties in a prone position, the first suggestion will be better supports or a different position (eg sidelying or on a chair) – only if this is refused, and only in a prone position, will it be allowed to removed it to enable treatment, and hand sanitiser will be given for the client to doff and to re-don.
14. Clean Air – Ventilation and Filtration		Window open for a minimum of 10 minutes before, during, and 10 minutes after all sessions. Curtains are not drawn completely across between the 2 halves of the units ( eg the consultation and treatment areas) to improve air flow throughout the unit. Air Filter units are 2 small Levoit LV-H128-RF on Level 3 (Double Air Inlet with 2 H13 True HEPA Filters, each of which has 3-Stage Filtration, a Pre-Filter, H13 True HEPA Filter and Activated Carbon Filter, removing 99.97% of particles as small as 0.3 microns) which each clean 69.66 m3/hr and 2 large Taotronic TT-AP003 on Level 3 which each clean 161m3/hr. The space is 128m3 and so the combined air purification of all 4 units is 6.69 ACH (Air Changes per Hour) or all air cleaned every 9 minutes.
15. Laundry	Storage Washing Touching Minimising person-to-person contact	Use of laundry service, industrial machines, washed at 60 degrees for towels, and 40 degrees for all other items, and tumble dried immediately. Dirty linens are placed in lidded lined hamper after each client. Avoid shaking laundry. When full, bin liners are tied closed and placed inside laundry bag for transport. There is a pick up and drop off collection system in place, using White Cross reception. Liner is thrown away by the Laundry Service staff when the laundry is taken out and put it in the machine. Laundry service required to put clean linens in a clean, closed plastic bag before placing back in laundry bag. Hands washed after touching dirty linens; after touching outer laundry bags; before touching clean linens.     Regular disinfection of laundry bags.
16. Client getting on and off couch	Potential transmission if assistance is required which requires close contact (eg lifting).	The majority of clients get on and off the couch independently. Intake forms ascertain if assistance is required. If the person needs assistance, it will be accessed whether that can be provided at an acceptable level of risk by the therapist or by a care worker or relative, or whether treatment must be refused.
17. Treatments - all	Close Contact - proximity - touch - Talking - breath - fluids Sharing an enclosed space (aerosols and droplets) transmission from client to therapist / from therapist to client / from client to other clients	In addition to measures detailed elsewhere (eg hygiene, laundry, ventilation, taking the consultation online, protective wear, use of mediums etc): Clients asked in new client email and in intake forms to only give necessary feedback, eg on pressure, comfort, but otherwise avoid talking, when supine and therapist is close to the high risk area. Therapist avoids unnecessary talking, especially when in same circumstance. Therapist takes care to avoid proximity to high risk area, and to avoid working face to face with client, eg by working from behind or from the side of the client, and changing position regularly. In the event of fire, the back door can be used, avoiding contact with other users of the building. Only limited treatment to face available - with face covering on.
18. Use of mediums	Cross - contamination	Pumps used for oils and washed after every client. Waxes and creams dispensed into glass container using spatula to prevent cross contamination. Clean glass jugs used for Aromatherapy oil blends.
19. Treatment –massage		Additional considerations: Indian head massage – the ‘Gentle Bliss’ option no longer offered as it involved extensive massage to the face not possible with a face covering, and positioning above the face of a supine client throughout. Use of chair as standard, or possible alternative of semi-supine position on couch.
20. Treatment – Hot Stones	Hot stones and equipment transmission risk	Additional considerations: Stones scrubbed with clean cloth and washing up liquid in hot soapy water with orange and lemon oil (for degreasing and anti-bacterial, anti-fungal and anti-viral effects) after use. Then soaked for 15 minutes in Miltons sterilising fluid. Then wiped dry. All other equipment including heater, scoop, tray, thermometer cleaned and added to sterilising fluid or sanitised with biocide spray. Fresh liner to hot stone heater each time it is used. Fresh flannels to wrap stones each time.
21. Treatment – Aromatherapy		Additional considerations: Essential oil box and bottles kept clean, and only touched with clean hands
22. Treatment – Reflexology		Additional considerations: Feet cleaned with cleansing wet wipes. If feet visibly dirty, alcohol based sanitizer or Dew Disinfect may be used in addition to this. Foot lotion contains anti-microbial essential oils, including lemon and geranium. https://pubmed.ncbi.nlm.nih.gov/32575476/ demonstrates their derivative compounds show significant ACE2 inhibitory effects which suggest that they are valuable natural anti-viral agents that may contribute to the prevention of the invasion of SARS-CoV-2 into the human body. If wooden tools used, cleaned and sanitized after use.
23. Between one client and the next – incl Cleaning		All used linens folded carefully and placed in lined hamper. Thorough cleaning and sanitising of the practice space, therapy table and equipment, including any surfaces touched by anyone, and all surfaces in the treatment area.
24. Waste Storage and Disposal		A foot-operated pedal bin with a lid and plastic liner for general ‘black bag’ rubbish. Bag sealed and disposed of appropriately, normally. If it becomes known that anyone has been present who had Covid-19, then the rubbish will be stored for 72 hours and double bagged before transport to the communal bins.
25. Deliveries – Inbound and Outbound Goods	Use of reception and post room – touch surfaces and difficulties of social distancing.	Deliveries to the therapist’s home address, or prompt collection of items from the post room, while masked and distancing from other users of the Business Park. See also, laundry.
26. Health Check – After Appointment		A Post Appointment Check-In will occur in the form of a reminder email to inform Holistyx if any Covid-19 symptom develop in the 10 days after the appointment.
27. Infection / Outbreak Management		If the therapist, someone within the therapist’s household, a client, or someone within the household of a client, becomes infected or shows symptoms within 10 days of attendance at Holistyx, given that Holistyx has been informed of this - anyone treated within 7 days will be contacted to inform them.
28. Training and knowledge	Transmission risk due to inadequate knowledge or skills to understand, interpret and evaluate relevant sources of information, legislation, regulations and guidance and to create and act on a thorough risk assessment.	To become a competent person, Ceri Turner has completed the course "Control of Cross-infection in a Post-COVID-19 World" by Jennifer Young Training School, and received the qualification. Ceri also regularly reads Covid research, checks the guidance of multiple Industry Associations, and of the government to ascertain the law, guidance and evidence based best practice.