Briefing on visiting care homes during COVID-19

The situation with COVID-19 is moving quickly, and while we have in place a series of webinars and other events to ensure elected members, officers and partners are updated, there are a number of issues which come up repeatedly or need slightly more detailed information. This briefing series is designed to provide accurate and up to date information on key issues. 

Guidance as at 12 April 2021

Government has published updated care home visiting guidance, applicable from 12 April 2021 in all care homes for working age and older adults.

This latest guidance should be read in conjunction with Government Guidance on lateral flow 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.

CQC are reporting concerns by relatives and resident’s associations about situations where they feel visiting is being unduly curtailed by care homes, or that ‘blanket bans’ are being imposed. CQC have released 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.

Visiting guidance: principles

  • Visiting by family and friends is vital to maintaining the health, wellbeing and quality of life of care home residents, as well as being essential for family and friends in maintaining contact and sustaining life-long relationships with their loved ones
  • Visiting must be supported by care homes wherever it is possible and safe to do so and ‘blanket bans’ on visiting are not appropriate
  • All care homes should enable the different types of visits described in the Guidance, within a care home environment that takes proportionate steps to manage and mitigate the infection risks associated with any increase in visitors
  • This means care homes finding the right balance between the benefits of visiting to the wellbeing and quality of life of individual residents, and the increased risk of transmission of COVID-19,including new variants of concern, to social care staff and other clinically vulnerable residents
  • Vaccination is not a condition for indoor or outdoor care home visiting, however it is strongly recommended that all visitors, staff and residents take the opportunity to be vaccinated when invited through the national vaccination programme
  • Given that each care home is unique in its physical layout, environment and facilities, and that residents needs 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
  • When developing visiting policy, the views of each individual resident, their needs and wellbeing should be always considered, while also recognising that care homes must balance this with the needs of others living and working in the care home
  • Individual visiting decisions should always involve the resident, or their representative, their family and friends, the care home, and other professionals such as social workers or clinicians as appropriate
  • Care home managers can also seek advice from their local Director of Public Health or Director of Adult Social Services, both of whom have an important role to play in supporting visiting, and in supporting visiting as set out in the Guidance. Resources provided by Care England and Partners in Care, a coalition of care providers, relatives and residents organisations facilitated by the National Care Forum, may be useful
  • Visits in exceptional circumstances such as end of life, and for essential care givers, should continue in all circumstances

Key messages

All care homes should:  

  • enable indoor visiting by up to two ‘named visitors’ per resident
  • enable residents with ‘higher level’ care needs to also nominate an ‘essential care giver’ who can provide close contact personal care where it is critical for the resident’s health and wellbeing; these essential care givers will follow the same testing, PPE and infection prevention and control (IPC) measures as care home staff
  • ensure all visitors take a lateral flow test (LFT) and test negative before every visit
  • ensure all visitors minimise physical contact with residents, maintain social distancing, use PPE and follow all necessary IPC measures
  • provide opportunities for every resident to see more than just their named visitors by enabling outdoor visiting and ‘screened’ visits wherever feasible
  • always enable visits in exceptional circumstances, including end of life
  • ensure visiting happens within a wider care home environment of robust IPC measures, including ensuring that visitors follow (and are supported to follow) social distancing, hand hygiene and PPE use

In the event of an active outbreak

  • Care homes should immediately stop all visiting until the outbreak is over, and any local outbreak management arrangements should be followed
  • During an outbreak, in order to protect vulnerable residents, staff and other visitors, visiting is only permitted in exceptional circumstances such as end of life, and for essential care givers
  • An outbreak is two or more confirmed cases of COVID-19 or clinically suspected cases of COVID-19 among individuals associated with a specific setting with onset dates within 14 days.

Setting visitor policy

  • The registered manager is responsible for setting the visiting policy in their home, taking  advice from their local Director of Public Health (DPH) as needed
  • Visiting policy should be developed from a dynamic risk assessment which takes account of the individual needs of their residents as well as the physical features unique to their setting eg the rooms or outdoor spaces in which visiting will happen, and where and how visitors might be received on arrival at the home to avoid mingling with other visitors, staff or residents
  • Risk assessments should follow the CQC regulatory framework for providing person centred care, and may involve care homes applying different rules for different residents or categories of resident, based on an assessment of individual risk of contracting COVID-19, as well as the potential benefits of visits to them
  • The risk assessments underpinning collective and individual visiting policies should be shared with residents, families and visitors to help explain the decisions which have been made about how visiting will operate
  • Care homes must consider the rights of residents who lack the relevant mental capacity needed to make decisions about visiting, and who fall under the Mental Capacity Act 2005 (MCA) and are protected by its safeguards. Where appropriate, advocates or those with power of attorney should be consulted about visiting arrangements, and if there is a deputy or attorney with relevant authority they must consent on the person’s behalf to any decision on visiting which affects them

Role of the Director of Public Health (DPH) and Director of Adult Social Services (DASS)

  • 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

Taking visiting decisions for particular residents or groups of residents

  • Some residents will have particular needs which 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 or advocates, to develop a tailored visiting policy which still operates within the principles outlined in the Guidance
  • 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
  • Being on the Shielded Patient List (SPL) does not prevent a care home resident from receiving visitors in the same way as other residents

Named visitors

  • Each resident can nominate up to two people for regular visits who will be tested using lateral flow tests (LFTs) supplied by the care home at every visit
  • The visitors must also wear appropriate PPE, maintain social distance and hand hygiene, and follow all other IPC measures as directed by the care home
  • Visitors should keep physical contact to a minimum but may hold hands, bearing  in mind that any contact increases the risk of transmission; no close physical contact such as hugging is permitted to reduce the risk of infection.
  • Where the resident lacks the capacity to nominate visitors, this should be discussed with the resident’s family, friends and others who normally visit or are identified in their care plan
  • In this situation, a person can only be nominated if this has been determined to be in the resident’s best interests in accordance with the Mental Capacity Act
  • In the case of illness, or other reason regular named visitors cannot continue to visit, care homes and families can take a pragmatic approach, with the aim of minimising change wherever possible
  • It is not a condition of visiting that the nominated visitors or the resident should be vaccinated, though this should be strongly encouraged 

Indoor visits

  • Residents can meet with their two named visitors at the same time or separately; essential care givers, where agreed, may also take part in these visits
  • Frequency and amount of time allowed for visits is for the care home to decide
  • Ad hoc or unannounced visits are not allowable so a simple booking or appointments system may be the best way to manage visiting
  • Visits should take place in a well-ventilated room, ideally using designated visiting rooms only used by one resident and their visitors at a time, and given regular, enhanced cleaning and ventilation between visits
  • Other areas used by visitors should be decontaminated several times throughout the day
  • Visitors should wear appropriate PPE, observing social distancing rules, good hand hygiene and any other IPC measures required by the care home 
  • Visitors should keep physical contact to a minimum; they may hold hands, but should bear in mind that any contact increases the risk of transmission; close physical contact such as hugging is not permitted

Outdoor and screened visits

  • Care homes should continue to enable visits in COVID-secure ways including behind substantial screens, in designated visiting pods, behind windows, or outdoors
  • 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
  • Visits should happen in the open air wherever possible eg an awning, gazebo or open-sided marquee, where visitor and resident must remain at least two metres apart at all times
  • 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 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 visitor to reduce the risk of viral transmission, along with good ventilation
  • 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

Exceptional circumstance such as end of life

  • Visits in exceptional circumstances such as end of life should always be supported and enabled, and families and residents helped to plan end of life visiting carefully, with the assumption that visiting will happen not just towards the very end of life
  • 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

Infection control precautions and the wider care home environment

  • All visitors and essential care givers must follow any guidance, procedures or protocols put in place by the care home to ensure compliance with infection prevention control; 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 ten days, is currently experiencing, or first experienced, coronavirus symptoms in the last ten 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 contacts should also self-isolate in line with current 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, such as a gift. 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.
  • 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

Testing arrangements for the named visitors

  • Government have produced detailed, step-by-step Guidance for care homes on how to conduct on-site lateral flow testing
  • Consideration is being given to whether the self-test at home kits now available to the general population through a number of different testing channels could be used in care homes to reduce the need for on-site testing by care homes. This briefing will be updated whenever anything is agreed about how this would work in practice
  • Care homes should obtain consent from visitors prior to participating in testing
  • Testing does not completely remove the risk of infection so care homes must be clear with visitors and residents that in addition to testing, social distancing, hand hygiene, use of PPE, and limited physical contact must continue
  • Any visitor who tests positive must immediately leave the premises to return home and self-isolate, avoiding public transport wherever possible. They should follow government guidance for households with possible or confirmed coronavirus (COVID-19) infection, and complete a confirmatory PCR test provided to them by the care home. This can be returned either through a courier or through a Royal Mail priority post box. If the confirmatory PCR comes back positive, their household must also self-isolate and contacts may also need to self-isolate in line with current government guidance for households with possible or confirmed coronavirus (COVID-19) infection
  • Visitors who have recently tested positive for COVID-19 should not routinely be retested within 90 days unless they develop new symptoms or unless specific infection detection and response plans are in place for individuals or in the local area already. This means that some visitors will not need to be tested regularly because they will still fall into this 90-day window. These visitors should use the result of their positive PCR result to show that they are currently exempt from testing until the 90-day period is over. Once the 90-day period is over, visitors should then continue to be tested. They should still continue to follow all other relevant IPC measures throughout these 90 days, including social distancing, maintaining good hand hygiene and wearing PPE.