Visiting guidance – English care homes and supported living from 19 July 2021

The DHSC’s guidance for care homes and for visitors has now been updated to reflect changes from 19 July 2021.   It makes clear that despite the removal of (most) legal restrictions on gatherings, face masks, etc discussed here, life for those in care homes and supported living placements will not return to how it was before March 2020.

It is worth reiterating that visiting people in care homes is not, and has not been, unlawful (save in the exceptional situation where a care home has been closed to visitors at the direction of a Director of Public Health).  The guidance continues to provide the framework through which care homes will make their decisions about visitors.   The updated guidance both reflects the changes in the public health environment, and also the impact of the work of bodies such as the Joint Committee on Human Rights in framing the difficult balancing acts required between the different rights in play.

In this post, I look at the main parts of the guidance document and also (so that things are in the same place) set out the other guidance documents relating to visits out of care homes (also now updated to reflect changes post 19 July 2021) and supported living.

For the position in Wales, Scotland and Northern Ireland, I recommend this very useful blog by Dr Oliver Lewis.

Care home guidance overview

The care home visiting guidance document is lengthy.   Its key messages are as follows:

  • every care home resident can nominate an unlimited number of ‘named visitors’ who will be able to enter the care home for regular visits (and will be able to visit together or separately as preferred).   There is now no ‘nationally set’ limit on the number of named visitors who can attend at a time
  • every care home resident can choose to nominate an essential care giver who may visit the home to attend to essential care needs. The essential care giver should be enabled to visit in all circumstances, including if the care home is in outbreak (but not if the essential care giver or resident are COVID-positive)
  • named visitors and residents are advised to keep physical contact to a minimum (excluding essential care givers). Physical contact like handholding is acceptable if hand washing protocols are followed. Close personal contact such as hugging presents higher risks but will be safer if it is between people who are double vaccinated, without face-to-face contact, and there is brief contact only
  • care homes can also continue to offer visits to friends or family members through arrangements such as outdoor visiting, rooms with substantial screens, visiting pods, or from behind window

As the guidance document notes:

Welcoming anyone into care homes from the community inevitably brings risk of COVID-19 transmission. However, these risks can be managed and mitigated, and they should be balanced against the importance of visiting and the benefits it brings to care home residents and their families.

[…]

In the face of new variants of the virus, and a potential upsurge in current prevalent types of COVID-19, we need to remain alert to risks to ensure we protect those most at risk in care homes while ensuring indoor visits can go ahead.

Vaccination is one of our best defences to combat infection. It significantly reduces the transmission of the virus, particularly following 2 doses. It is strongly recommended that all visitors and residents take the opportunity to be vaccinated before conducting visits. 

The DHSC emphasises that responsibility for deciding upon visits remains with care homes:

Each care home is unique in its physical environment and facilities, and the needs and wishes of their residents. As such, care home managers are best placed to develop policies (in consultation with residents and their relatives) to ensure that the visits described in this guidance are provided in the best way for individual residents, their loved ones, and care home staff.

Care home managers should feel empowered to exercise their judgement when developing practical arrangements or advice to put this guidance into practice so that visiting can take place smoothly and comfortably for everyone in the care home.

If the provider or manager has any queries regarding visiting, a range of additional support is available. They may wish to 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 the care home to deliver the visits described in this guidance. Additionally, care homes may wish to make use of the resources provided by Care England and Partners in Care, a coalition of providers, relatives and residents organisations facilitated by the National Care Forum.

The individual resident, their views, their mental capacity, their needs and wellbeing should be taken into account when decisions about visiting are made, recognising that the care home will need to consider the wellbeing of other residents as well.

These decisions should involve the resident, their family and friends and the provider and other relevant professionals such as social workers or clinicians where appropriate. Throughout this guidance we use the phrase ‘family and friends’. This is intended to be a wide-ranging and inclusive term to describe the network of people around the resident who may wish to visit, or whom the resident may wish to meet.

All decisions should be taken in light of general legal obligations, such as those under the Equality Act 2010 and Human Rights Act 1998, as applicable. Providers must also have regard to the Department of Health and Social Care (DHSC) ethical framework for adult social care. The Care Quality Commission (CQC) has regulatory powers that can be used where the commission has concerns regarding visiting.

The starting point in the guidance is that

Visiting must be supported wherever and whenever it is possible and safe to do so – and a wide range of professionals have a role in supporting this, including care home managers, DPH and DASS.

As the default position, all care homes should seek to enable the different types of visits described in this section.

Care home guidance – section by section

Section 1 of the guidance sets out the framework for developing a visiting policy, and, in 1.2, the roles of the Director of Public Health and Director of Adult Social Services.   It makes clear that blanket bans covering whole local authority areas are not appropriate.

Section 1.3 sets out advice for making decisions about particular residents or groups of residents, noting that

Providers must consider the rights of residents who may lack the relevant mental capacity needed to make particular decisions. This will include residents who lack the capacity to decide who they wish their single named visitor to be [this must be a typo as it does not reflect the current limit]. For example, some people with dementia and learning disabilities may lack the relevant capacity to decide whether or not to consent to a provider’s visiting policy. These residents will fall under the empowering framework of the Mental Capacity Act 2005 (MCA) and are protected by its safeguards. Where appropriate, their advocates or those with power of attorney should be consulted, and if there is a deputy or attorney with relevant authority they must make the best interests decision to consent on the person’s behalf to the visiting policy.

When considering their visiting policy, staff will need to consider the legal, decision-making framework, offered by the MCA, individually for each of these residents and should not make blanket decisions for groups of people. The 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.

The guidance also emphasises that:

Care homes must also take into account the significant vulnerability of residents in most care homes, as well as compliance with obligations under the Equality Act 2010 and the Human Rights Act 1998, as applicable.

Section 1.4 sets out what should happen if there is an outbreak – i.e. the stopping of all visits except for exceptional circumstances.

Section 2 then sets out how to deliver safe visiting, with section 2.1 setting out details of the ‘named visitor’ approach.

The care home should ask each resident who they would like as their named visitors. These should remain unchanged, within reason.

Although the number limit on named visitors is now lifted, residents should still identify their named visitors to the care home so they can be supported for the necessary testing and support required to facilitate COVID-secure visits.

The intention is that these people are named by the resident but

Where the resident lacks the capacity to make this decision, the care home is encouraged to discuss the situation with the resident’s family, friends and others who may usually have visited the resident. 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 empowering framework of the Mental Capacity Act. (See also the advice in section 1.3 for those who lack relevant capacity.) Where necessary, social workers can be approached by the care home, resident or family to support these conversations – in particular to help resolve any issues or concerns, and to ensure professional support and or oversight where required.

The guidance then sets out details of how visits can be conducted and testing arrangements.

In section 2.2, the guidance develops the concept of the ‘essential care giver.’  As the guidance goes on to develop:

The essential care giver arrangements are intended for circumstances where the visitor’s presence or the care they provide is central to the immediate health and wellbeing of the resident. It is likely that the requirement for this support from the resident’s loved one will already be part of (and documented in) their care plan – although this should not be considered a condition of this type of visit.  Managers should not assume that, in order to fulfil this role, an essential care giver must commit to visiting a specific number of times each day or week – the care and support provided may still be critical even if it is not provided every day.

Visits of this type are considered to be within the definition of ‘exceptional circumstances’ and – together with the care home’s responsibility to carry out individualised risk assessments where necessary – have been part of our visiting guidance previously, including throughout the most recent period of national restrictions. We intend that this guidance will provide the clarity needed to help these visits to take place; and the extra support described here will enable them to take place more safely.

Importantly, essential care givers are:

a central part of delivering the appropriate care and support to the resident, and as such play a role alongside professional members of the care home staff. Additionally, because they will have closer physical contact with the resident, and may spend longer in and around the care home, including areas that other visitors do not enter – it is important that they take further steps to reduce the risks (to themselves to residents and staff members) of infection.

The (relatively onerous) requirements as regards testing and PPE for such essential care givers are then developed, before the guidance notes that:

It is not a condition of visiting that the visitor or resident should have been vaccinated. However, it is recommended that they take up the opportunity to be vaccinated when they are invited to do so through the national programme.

It is important that these visitors agree with the care home what tasks they will and will not be undertaking, and that all involved are confident that the visitor has the skills to perform those tasks safely (this may well include risks not related to COVID such as skills for lifting and handling). These visitors must also agree to follow any advice or instructions on IPC from care home staff.

The care home and visitor should also agree any other relevant arrangements – for example, when and how often the visitor will come to the home, and communal areas such as staff rest areas that the visitor should not enter. Care homes may want to consider what access to refreshments may be necessary.

It is a good idea that these sorts of arrangements and any necessary training is written down and agreed between the care home manager and the visitor. Clinical care and medical tasks such as the administering of medication and physiotherapy remains the responsibility of the care home.

Section 2.3 addresses outdoor and ‘screened’ visits, the key message being that:

Wherever possible, care homes should also continue to enable other types of visits set out below (including behind substantial screens, in designated visiting pods, behind windows or outdoors), for those who are not ‘named visitors’ but wish to visit residents.

We recognise that providers themselves are best placed to decide how such visits will happen in practice, considering the needs and wellbeing of individual residents, and the given layout and facilities of the care home.

Section 2.4 addresses exceptional circumstances such as end of life, the key message being that:

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.

Visits of this nature should be tested using supplied rapid lateral flow tests. For information on how to test, please see the care home rapid lateral flow testing of visitors guidance.

Essential care givers should continue to follow the advice provided above in section 2.2 above. This section relates to those who are not essential care givers.

Section 2.5 addresses infection control procedures and the wider care home environment, and 2.6 provides important guidance about communication, reminding care homes that:

All visitors have a very important role to play in keeping people safe by taking steps to reduce the risks of infection wherever possible. It is important that visitors observe 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.

It is important for providers to help visitors understand these risks, and their role in managing them to keep loved ones safe.

It is important that all visitors follow any advice and instructions that the care home provides – in order to reduce risks to themselves and their loved ones as much as possible.

Importantly, the guidance emphasises that:

Friends and family should be advised that their ability to visit care homes is still subject to the specific circumstances of the care home and those living and working within it. This is likely to mean that the frequency of visits is limited and/or controlled.

It is recommended that the home has an arrangement to enable booking/appointments for visitors. Ad hoc visits cannot be enabled.

[…]

If there is a restriction to visitors in place, alternative ways of communicating between residents and their families and friends should be offered. The care home should also provide regular updates to residents’ loved ones on their mental and physical health, how they are coping and identify any additional ways they might be better supported, including any cultural or religious needs.

Visitor guidance

In a one page guidance document (also updated to reflect changes from 19 July 2021), the DHSC summarises the care home visiting guidance.  Helpfully, it also then has these two sections:

If the care home makes a decision you disagree with

If the care home makes a decision you disagree with, it would be best to speak to the care home manager and ask to discuss the situation.

You could ask about the risk assessment the care home has developed to decide its visitor policy.

You could consider asking the care home to do an individual risk assessment for your loved one.

If this does not help, you could consider contacting a social worker at your local authority. They may be able to discuss the situation with you and the care home manager to find a solution.

Sometimes there will be good reasons (like an outbreak) why the home cannot offer the visiting you would like. But our guidance clearly says that the care home should not put blanket restrictions in place.

Care homes not offering visits

The government’s guidance says that visiting should be allowed to happen wherever it can be done safely.

Care home managers and staff will know best how things should run in their care home. For example, there might have to be limits on how many visitors can come in, or how often, because of the amount of space or layout of the rooms.

Sometimes there will be good reasons (like an outbreak) why the home cannot offer the visiting you would like.

But our guidance clearly says that the care home should not put blanket bans in place.

We expect all care homes to do what they can to follow our guidance. And they should explain to everyone what they are doing and why.

If you think the care home is not doing this please raise the matter with the home. If you are not satisfied that the issue is resolved, you can contact the Care Quality Commission (CQC). [contact details then given]

Visits out of care homes 

The DHSC has published guidance on visits out of care homes.  It was most recently updated on 15 July 2021.  Its core message is as follows:

Opportunities for care home residents to make visits out of the home are an important part of care home life.

Even as vaccine coverage increases, there are still risks involved in visits out. It’s important that care homes, residents, family and friends take steps to manage and mitigate these risks.

The guidance identifies that:

There are certain types of activity where the risks are inherently higher and will mean that the resident should self-isolate on their return (to the care home). This is to ensure that, in the event they have unknowingly become infected while out of the home, they minimise the chances of passing that infection on to other residents and staff. These activities are:

    • overnight stays in hospital
    • visits assessed to be high-risk following an individual risk assessment

Importantly:

All other visits out of the care home that are not assessed as high risk should be supported without the need to isolate on return to the care home, subject to an individual risk assessment (see section on individual risk assessments below). Where applicable, attention should also be given to any additional local guidance provided by the local director of public health (DPH) and director of adult social services (DASS).

The guidance continues

All precautions relating to COVID-19 (including social distancing and those set out below) should be followed while out of the care home. Where residents are visiting a location with an existing testing regime – for example a workplace, day care centre or education setting – they should participate in the relevant testing regime for that organisation where possible.

The guidance sets out steps for individual risk assessment, taking account in particular

  • the vaccination status of residents, visitors and staff, including the extent of 2nd vaccinations
  • any testing of those accompanying the resident or who they intend to meet on their visit out
  • levels of infection in the community
  • variants of concern in the community
  • where the resident is going on a visit and what activities they will take part in while on the visit
  • the mode of transport that residents intend to use

The guidance sets out steps to mitigate risks during a visit out, including:

  • if appropriate, residents being accompanied by:
      • a member of care home staff
      • one or more of their named visitors, and/or
      • their essential care giver (where applicable)
  • residents maintaining distance from anyone who is not one of their named visitors, essential care givers, or care staff and, wherever possible, avoiding close physical contact with those who are supporting their visit to minimise the risk of infection
  • residents avoiding crowded places
  • residents avoiding using public transport where possible, especially at peak times; travelling in a family car or private taxi is an acceptable alternative

If there is an outbreak:

all movements out of a setting should be minimised as far as possible.

These restrictions should continue until the outbreak is confirmed as over, which will be at least 14 days after the last laboratory confirmed or clinically suspected cases were identified in a resident or member of staff in the home.

Supported living 

The guidance for supported living was updated on 15 July 2021 to take account of the changes from 19 July, as follows:

From 19 July 2021, there are no restrictions on the number of people individuals can meet. People living in supported living settings live in their own homes and visits should be supported and enabled wherever it is safe to do so.

However, a supported living setting may also be a staff workplace and include a range of communal areas and shared facilities. It is therefore important to consider the risks arising from visits, to those taking part, as well as the risks for others with whom they live, or may later come into contact.

When planning a visit into or out of the setting, providers, and care and support workers, should work with individuals and their families to consider their needs and maximise their safety. This will enable people being supported to make decisions about visits out of the home, and how these visits can be made possible.

There are risks that need to be considered – even where people are vaccinated – but these are risks that can be appropriately managed through limiting close contact, use of face covering, staying at home if unwell, good hand and respiratory hygiene and testing twice a week.

Individuals visiting a setting with an existing testing regime (for example a workplace, day care centre or education setting) should participate in the relevant testing regime for that setting or organisation where possible.

Therefore, in all cases, arrangements for visiting into and out of the setting should be supported by a dynamic risk assessment for the overall setting, as well as an individualised assessment of the benefits of visiting and the risks to particular people because of their care and support needs. The risk assessment should consider people’s rights and decisions should balance the resident’s assessed needs against the consideration of risk of infection. The risk assessment will also need to reflect whether the setting is a ‘high risk’ setting (as designated by the local director of public health).

For visits taking place at the setting, the manager may also wish to consider:

    • if a setting has a communal garden area which can be accessed without anyone going through a shared building, then using this space for visits should be encouraged
    • if, in shared accommodation, visitors should limit close contact with other people who live there and staff
    • visitors should be reminded and provided with facilities to wash their hands for 20 seconds or use hand sanitiser on entering and leaving the home, and to catch coughs and sneezes in tissues and clean their hands after disposal of the tissues

For visits taking place away from the setting, the manager should consider:

    • testing visitors who are collecting residents and transporting them to or from the setting, and encouraging any others they may be meeting to conduct a test on the day
    • offering support so people can find or go to outside spaces to see their relative in a safer environment
    • factors to minimise the risk for staff and other individuals in the supported living setting (including the layout of the premises and the nature of the support provided)
    • the nature and context of the visit – for example, whether the visit would include overnight stays in the family home or visits to a public place
    • the support needs that the person may have during the visit, and whether they will need to be accompanied by a staff member, carer, family member or friend
    • transport for the visit should avoid exposing the person to those outside the household they are visiting, for instance by travelling in a family car wherever possible
    • increased communal risks that may arise in shared areas when people return from off-site visits (including shared spaces indoors and outdoors, on-site grouped services and social activities)
    • the need for those returning from off-site visits to visits to self-isolate if they test positive for COVID-19, or have been notified by NHS Test and Trace that they have been in contact with someone who has tested positive for COVID-19. There is no expectation for someone to self-isolate for 14 days after a visit has happened if this is not the case

And in all cases, the manager should work with people being supported and their families to:

    • make sure that no one with COVID-19 symptoms should participate in a visit and anyone with suspected symptoms should be tested
    • make sure that no one visits when an individual is required to self-isolate as they have been a close contact of a COVID-19 case in the previous 10 days, and whether an individual needs to self-isolate if they have travelled to certain countries
    • remind them to follow good infection control practice including avoiding close contact, hand hygiene and face coverings, and to consider whether their needs are likely to impact their ability to do so
    • where possible, visitors can be given support on how to prepare for a visit and given tips on how to communicate if face coverings are required

The supported living guidance goes into considerable detail about testing, noting that

Rapid lateral flow testing should not be seen as a condition of people in supported living taking part in visits in and out of the setting, but as a tool to support safer visits alongside other IPC measures. For clarity people who test positive or those who are known contacts of a positive case should be isolated according to public health guidance, and testing cannot be used during an isolation period to enable earlier release.

Managers may wish to consider testing people living in high risk settings with rapid lateral flow tests if they are often leaving the premises to meet or visit people. This is similar to testing for people who are unable to work from home who can access twice weekly lateral flow testing from their local asymptomatic testing site. Twice weekly testing for people who live in supported living can be conducted on site, assisted by a staff member.

In relation to those with impaired decision-making capacity, the guidance notes that

Any visiting arrangements should be made in agreement with the person being supported. If the person is assessed as not having capacity in relation to this decision, the provider should work within the appropriate MCA framework to establish whether the arrangements are in the person’s best interests. The government has published advice on the MCA and application of Deprivation of Liberty Safeguards (DoLS) during the pandemic.

Regard should also be given to the ethical framework for adult social care, and the wellbeing duty in section 1 of the Care Act 2014, and all decisions should be taken in light of general legal obligations, such as those under the Equality Act 2010 and Human Rights Act 1998, as applicable. Social workers can help providers to meet these duties by providing advice in individual cases should that be required.

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