Briefing on visiting care homes during COVID-19

Government has published updated care home visiting guidance, (the guidance) applicable from 16 August 2021 in all care homes for working age and older adults.

This latest guidance should be read in conjunction with Government Guidance on the testing of visitors to care homes, and Guidance on the testing of professional visitors to care homes, including CQC Inspectors, Nurses, Doctors and social workers, updated on 7 July 2021

CQC have highlighted concerns by relatives and resident’s associations about situations where they feel visiting is still being unduly curtailed by care homes, or that ‘blanket bans’ are being imposed. CQC have published a statement on visiting in care homes, emphasising the rights of individuals when setting visiting policies

Government have also published a helpful summary of the visiting guidance for families and friends hoping to visit loved ones in a care home, updated on 3 August 2021

Key messages

• Visiting is important for maintaining the health, wellbeing and quality of life of care home residents, and for enabling family and friends to maintain contact and life-long relationships with their loved ones
• Care home visiting should be supported and enabled wherever possible to do so safely and within an environment that manages the risks associated with visiting during the current pandemic
• Visitors also have an important role to play in keeping themselves and those living and working in care homes safe by following the policies set out in the guidance, and the practical arrangements that individual care homes put in place to manage infection risks
• Local directors of public health (DPH) and directors of adult social services (DASS) also have a key role in enabling visiting and care home managers can seek support from them in enabling visiting as described in the guidance
• In the face of new variants of the virus, it’s important to remain alert to protect those most at risk in care homes, while also ensuring indoor visits can go ahead
• It is strongly recommended that all visitors and residents take the opportunity to be fully vaccinated before visits to care homes although vaccination is not a condition of care home visiting
• Given that each care home is unique in its physical layout, environment and facilities, and that residents needs and wishes will vary, individual care home managers are best placed to decide how visits should happen in their care homes, in ways which best meet the needs of their residents, both individually and collectively
• Care home managers should feel empowered to exercise their judgement when developing practical arrangements or advice to put visiting guidance into practice
• Additional support is available in support of care home visiting from Care England and Partners in Care, a coalition of care providers, relatives and residents organisations facilitated by the National Care Forum
• Individual residents, their views, their mental capacity, their needs and wellbeing should be taken into account when decisions about visiting which affect them are made, recognising that care homes will also need to consider the wellbeing of other residents and staff
• Visiting decisions should involve the resident, their family and friends,the care home and other relevant professionals such as social workers or clinicians where appropriate; the phrase ‘family and friends’ in the guidance means the network of people around the resident who may wish to visit, or whom the resident may wish to meet.
• When taking visiting decisions, care home managers should take account of their general legal obligations including those under the Equality Act 2010 and the Human Rights Act 1998,as well as the Department of Health and Social Care’s (DHSC) ethical framework for adult social care. The Care Quality Commission (CQC) also has regulatory powers that can be used where there are concerns about the operation of visiting policies within care homes
• Visits in exceptional circumstances such as end of life should continue in all circumstances (including in the event of an outbreak); for those approaching the end of their lives, this should not just mean at the very end of one’s life,and discussion with families and residents about visits in these circumstances should happen in good time
• Visiting is equally important for people living in supported living and extra care settings and while this guidance does not directly apply to those settings, supported living and extra care managers may wish to use the guidance to help them support safe visiting; to support safe visiting, additional lateral flow testing has also been provided for visitors in supported living and extra care settings where staff are currently eligible for testing.

Key messages

• Care home managers are best placed to design individual visiting arrangements that take account of the needs of their residents and what is possible within the layout and facilities in their care home
• In this context, the provider must develop a dynamic risk assessment that assesses how the care home can best manage visits safely,and should should consider relevant factors relating to the rights and wellbeing of the residents
• Any risk assessment should follow the CQC regulatory framework for providing person centred care; it may also be necessary for providers to apply different rules for different residents based on their assessment of risk of contracting COVID-19 in relation to each  resident, as well as the potential benefits of visits to them. The risk assessment should also consider the need to enable essential care giver visits described in section 2.2 of the guidance.
• The risk assessment should also consider factors including the layout, facilities and other issues around the care home to help decide where visiting will happen, including the rooms or outdoor spaces in which visiting will happen, where and how visitors will be received on arrival at the home to avoid mingling with other visitors, staff or residents,and the precautions that will be taken to prevent infection during visits (including PPE use and hand washing)
• Care home managers should share their risk assessments and underpinning visiting policies with residents or their families, including updates on any changes, to help explain the decisions they have made, and their visiting policy

Key messages

• The local DPH and DASS have an important role in supporting care homes to ensure visiting happens safely and should support visiting arrangements as set out in this guidance, unless there is evidence that a more restrictive approach in a particular care home for a particular period is required
• A DPH may provide advice for specific care homes, or provide a local framework and guidance relevant to a particular geographical area, however the default position is that visits should be supported and enabled; ‘blanket bans’ on visiting which cover a whole council area’s care homes are not appropriate
• Any locally developed guidance affecting care home visiting should enable care homes to exercise discretion on visiting policy, depending on their individual circumstances
• A DPH may also give direction to a specific home about steps they are required to take in order to allow visiting safely -including a Notice or Direction pursuant to the Public Health (Control of Disease) Act 2020 or a Direction pursuant to the Coronavirus Act 2020.

Key messages

• Some residents have particular needs which may present a challenge for care homes in fully implementing the visiting Guidance 
• Where this is the case eg where a person in unable to leave their room, lacks mental capacity or is living with dementia, care homes should work with the resident, their family, friends and any volunteers, advocates or social workers, to develop a tailored visiting policy which still operates within the principles outlined in the Guidance as far as possible
• The rights of residents who lack the relevant mental capacity needed to make particular visiting decisions such as who should be their named visitors or essential care giver,should be considered, and advocates or those with power of attorney consulted so that a best interests decision to consent on the person’s behalf to the visiting policy can be taken
• Care homes should not make blanket decisions for groups of people in their care, and should also take account of the ethical framework for adult social care and the wellbeing duty in s1 of the Care Act 2014 and comply with their obligations under the Equality Act 2010 and the Human Rights Act
• Government has published advice on caring for residents without relevant mental capacity, the MCA and Deprivation of Liberty Safeguards (DoLS) during the pandemic, setting out what relevant circumstances should be considered when making best interest decisions

Key messages

• In the event of an outbreak, visiting should stop immediately, except for exceptional circumstances such as end of life
• Essential care givers can continue to visit, but not if they or the resident are COVID-positive
• Risk assessments for window visits during an outbreak can be undertaken,taking account of the impact of the outbreak and staff capacity to facilitate window or other visits without breaching zoning or cohorting of residents and staff
• Health protection teams and infection control leads, and other partners, can provide advice to care homes to help with risk assessments
• Local policy and outbreak management arrangements should be followed, and should continue until the outbreak is confirmed as over
• Recovery testing should be carried out 14 days after the last positive test result.

Key messages

• Each care home resident can have named visitors, these should remain unchanged, within reason; there is no limit on numbers of named visitors a resident can have
• These visitors should be tested using lateral flow tests on the day of every visit and produce a negative COVID test prior to their visit, and should wear appropriate PPE and follow all other infection prevention and control measures as set out in the guidance, and by individual care homes
• Visitors are advised to keep physical contact to a minimum
• Where a resident lacks the capacity to make a visiting decision, this should be discussed with the resident’s family, friends and others who usually visit, or are identified in their care plan; a person can only be nominated if this is in the resident’s best interests in accordance with the framework of the Mental Capacity Act
• It is not a condition of visiting that the nominated visitors or the resident should be fully vaccinated, though this should be strongly encouraged
• Testing named visitors:  onsite testing is preferable for assurance purposes however care home managers can allow evidence of a recent negative test if it has been taken that day
• If visitors are not able to produce a negative test, they may be asked to reschedule their visit  or be prepared to take a test on site.
• If the visitor tests positive, they must immediately self-isolate once notified by Test and Trace and follow guidance for households on self-isolation.They should also complete a confirmatory PCR test which should be provided to them by the care home if testing on site, or ordered from the government portal or by calling 119. If the follow-up PCR result is negative, and was taken within 2 days of the positive lateral flow test, self-isolation is not necessary.

Key messages

• All residents can benefit from a visit from a loved one who provides a greater degree of personal care or support to maintain their health and wellbeing than a usual visitor
• This option should be available to all residents
• Essential care givers will need to follow the same testing arrangements and PPE and infection control arrangements as care home staff
• Exact arrangements will need to be agreed between the care home, resident and their family following an individual assessment of the resident’s needs
• Essential care givers should be strongly encouraged to receive 2 doses of vaccine before visiting
• From 16 August, care givers who have been fully vaccinated no longer need to self-isolate if identified as a close contact of someone who has tested positive for COVID-19; it is recommended that if a fully vaccinated essential care giver is identified as a close contact of someone who has tested positive for COVID-19, they do not visit the care home until they have received a negative PCR test, and test negative on a lateral flow test on the day of their visit.
• Essential care givers who are not fully vaccinated should not visit the care home for 10 days following contact with a COVID-19 positive case.

Key messages

• Care homes should continue to enable visits for visitors who are not ‘named,’ including behind substantial screens, in designated visiting pods, behind windows or outdoors
• Visits should happen in the open air wherever possible (including under cover such as an awning, gazebo or open-sided marquee).
• Care homes are best placed to decide how such visits will happen considering the needs and wellbeing of individual residents, and layout and facilities of the care home
• A dedicated room such as a conservatory,ideally one which can be entered directly from outside, can be used
• In all cases, the visiting space should only be used by one resident (accompanied if appropriate by an essential care giver) and their visitor(s) at a time, with regular enhanced cleaning between each visit; visitors should enter the space from outside wherever possible
• There should be a substantial screen between the resident and visitors to reduce the risk of viral transmission, along with good ventilation and use of speakers/aids to hear to reduce need for raised voices
• PPE must be used throughout the visit, and around the care home building and grounds, with social distancing (between visitors and residents, staff, and visitors from other households) maintained at all times and high-quality IPC practiced throughout the visit, and in the wider care home environment.

Key messages

• Visits in exceptional circumstances such as end of life should always be supported and enabled
• Families and residents should be supported to plan end of life visiting carefully, with the assumption that visiting will be enabled to happen not just towards the very end of life, and that discussions with the family take place in good time
• Visitors should be tested using lateral flow tests and essential care givers should continue to follow the advice provided in the guidance
• End-of-life care for residents in care homes means early identification of those who are in their last year of life and offering them the support to live as well as possible and to then die with dignity
• NHS guidance on end-of-life care is available to support this process, as well as advice from the British Geriatric Society.

Key messages

• All visitors and essential care givers must follow any guidance, procedures or protocols put in place by the care home; these should  be available for reading by visitors on arrival
• These measures must include use of PPE, good hand hygiene, use and disposal of tissues for  coughs and sneezes, and social distancing throughout the visit, even where both resident and visitor have received a COVID-19 vaccine
• All visitors should be screened for symptoms of acute respiratory infection before entering, and anyone who has tested positive for COVID-19 in the last 10 days, is currently experiencing, or first experienced, coronavirus symptoms in the last 10 days should not be allowed to enter the premises, nor anyone who is a household contact of a case or who has been advised to self-isolate by NHS Test and Trace, or who is in a relevant quarantine period following return from travel.
• Any potential visitor who tests positive with a lateral flow test should immediately leave the premises and return home, avoiding public transport if possible, to self-isolate. They should be offered a confirmatory PCR test by the care home and if this is positive, their household follow current self-isolation guidance
• The Guidance (2.5) includes some suggested screening questions which care homes may wish to ask all visitors on arrival
• Staff should discuss with visitors any items they wish to bring on their visit as it will need to be easily cleaned by the care home to prevent cross contamination eg a box of chocolates that could be sanitised with wipes
• Any visits involving children should be carefully considered and arrangements for the visit,especially the numbers involved and where the visit will take place,must be planned and agreed with the care home in advance of any visit
• Care homes should support NHS Test and Trace by keeping a temporary record (including address and phone number) of current and previous residents, staff and visitors (including the person/people they interact with).

Key messages

• Care homes should provide a clear visiting policy which explains to visitors their role in managing them to keep their loved ones safe by providing a clear visiting policy
• This will include all visitors observing social distancing, PPE and hand hygiene practice while in and around the care home, including during the visit itself, although some close contact may be possible where testing and PPE is in place to mitigate risk
• All visitors should follow any advice and instructions that a care home provides in order to reduce risks to themselves and their loved ones as much as possible
• The guidance (2.6) provides tips on what could be included in a care home visiting policy and how people can prepare for their visits.