Visiting guidance – English care homes and supported living

The DHSC’s guidance for care homes has been largely rewritten in November 2021, and now incorporates previously separate guidance about visits out of care homes.

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  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.

The DHSC’s Adult Social Care Winter Plan for 2021-22 emphasises the importance of visiting in care homes.

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 material relating to visits in the guidance for supported living placements.

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:

There are no nationally set restrictions on friends and family visiting their loved ones in care homes. We expect and encourage providers to facilitate visits wherever possible, and to do so in a risk-managed way.

Visiting is an integral part of care home life. It is vitally important for maintaining the health, wellbeing and quality of life of residents. Visiting is also crucial for family and friends to maintain contact and life-long relationships with their loved ones, and to contribute to their support and care.

People living in care homes are typically more vulnerable to severe illness as a result of coronavirus (COVID-19). While vaccination is proving very effective, we are still seeing some cases of severe illness, hospitalisation and death of care home residents who have been vaccinated.

Additional measures are therefore in place to facilitate visiting while keeping care home staff and residents safe. These include infection prevention and control (IPC) measures, individual risk assessments, testing arrangements and isolation on return from some high-risk activities out of the home.

It starts with a number of key things to know about care home visiting:

  • visitors should make arrangements with care homes in advance of the visit
  • the duration of visits should not be limited
  • visits should take place in a room most practical and comfortable for the resident (for example, residents with dementia may be more comfortable in their own room with familiar belongings)
  • visitors should receive a negative lateral flow test on the day of their visit, either by conducting the test at home or when they arrive at the care home. Essential care givers need to follow additional testing arrangements outlined below
  • every care home resident should be supported to have an essential care giver who may visit the home to offer companionship or help with care needs. Essential care givers should be able to visit inside the care home even during periods of self-isolation and outbreak
  • during an outbreak, care providers should also continue to offer visits in well-ventilated spaces with substantial screens, visiting pods or from behind windows. Rooms should be left to ventilate with external doors and windows open between uses wherever possible, if a comfortable temperature for residents and visitors can be maintained
  • subject to a risk assessment by the health protection team (HPT), in some circumstances some outbreaks may be considered over when there have been 2 rounds of whole home polymerase chain reaction (PCR) testing, taken 4 to 7 days apart, which are both negative. This means that effectively some outbreaks could be declared over after 7 to 8 days (rather than 14 days), subject to other considerations. An outbreak of a variant of concern could still see more prolonged and significant restrictions
  • physical contact should be supported to help health and wellbeing, as long as infection prevention and control measures are in use, such as visiting in a ventilated space, using appropriate personal protective equipment (PPE) for the visit, and hand-washing before and after holding hands. Gloves are not needed for hand-holding
  • residents should be supported to undertake visits out of the care home and will only need to isolate following an emergency stay in hospital if they test positive for COVID-19, or following a visit that has been deemed high-risk following an individual risk assessment
  • vaccination is one of our best defences to combat infection. The COVID-19 vaccine significantly reduces the transmission of infection, particularly after 2 or more doses. It is strongly recommended that residents and visitors receive 2 doses of the COVID-19 vaccine, plus their booster where applicable. If eligible, visitors should also get their flu jab when it is offered to them
  • visitors should not enter the care home if they are feeling unwell, even if they have tested negative for COVID-19 and are fully vaccinated. Transmissible viruses such as flu, respiratory syncytial virus (RSV) and norovirus can be just as dangerous to care home residents as COVID-19. If visitors have any symptoms that suggest other transmissible viruses, such as cough, high temperature, diarrhoea or vomiting, they should avoid the care home until at least 5 days after they feel better
  • visitors who are not legally required to self-isolate are advised against visiting the care home if they have been identified as a close contact of someone with COVID-19, unless absolutely necessary, even if they have been fully vaccinated. Where visits do occur, visitors should have received a negative PCR test result prior to their visit, and a negative lateral flow test result earlier in the day of their visit.

The guidance document is then broken into the following sections:

  • visits that should happen in all circumstances
  • safe visiting practices
  • when different visiting arrangements are needed
  • sources of information and support

Visits that should happen in all circumstances 

This section outlines specific considerations relating to three categories of visits which should happen in all circumstances: (1) visits by essential care givers; (2) visits in end of life situations; and (3) professional visits.   In respect of essential care givers, the guidance notes as follows in relation to those with impaired decision-making capacity:

Where the resident lacks the capacity to choose their essential care giver, the care home should discuss the situation with any attorney or deputy, the resident’s family, friends and others who may usually have visited the resident or are identified in the care plan. In this situation, a person can only be nominated as an essential care giver if this has been determined to be in the resident’s best interests in accordance with the empowering framework of the Mental Capacity Act (MCA) 2005. Consideration should be given to whether there is an attorney or deputy with appropriate authority to make this decision.

Safe visiting practices 

This section develops guidance in relation to (1) infection protection and control; (2) risk assessments; (3) testing arrangements; (4) visits out of care homes; (5) communicating with families and visitors.   In relation to risk assessments, the guidance emphasises that:

When developing risk assessments for residents who are assessed as lacking the relevant mental capacity, providers will need to consider any appropriate legal frameworks, including the MCA. Decisions should be made individually for residents and blanket decisions should not be made for groups of people. The resident should be involved as far as possible in decision-making, and providers should consult with their family and friends on what the person would want for themselves.

In relation to visits out, the key message is that

We expect and encourage providers to facilitate residents to take part in visits out of the care home. This could be for a short walk, to attend a place of worship or for a longer visit including an overnight stay to see family and friends.

And that:

If a resident with the relevant mental capacity wishes to go out, then in most cases members of staff at the home cannot lawfully prevent them from doing so.

If a resident is assessed as lacking the relevant mental capacity to decide to go out, they should still be involved in decision-making as much as possible and their family and friends consulted. The decision-maker should, where necessary, make a best interests decision under the MCA regarding this decision, following the best interests decision checklist as set out under the MCA. Providers should always consider less restrictive options. In certain cases, these arrangements may amount to a ‘deprivation of liberty’, in which case legal authorisation is required and it is important that decision-makers comply with their legal requirements for this. The NHS provides more information on applying the MCA.

The guidance further provides in this latter regard:

Providers must consider the rights of residents who may lack the relevant mental capacity needed to make a decision about visits out of care homes. These people are protected by the empowering framework of the MCA and its safeguards. Where practicable and appropriate, their advocates and those with power of attorney should be consulted, as well as any deputy, and if there is a deputy or attorney with relevant authority, they must make the best interests decision regarding the visiting policy on the person’s behalf.

When different visiting arrangements are needed 

This section addresses the following situations: (1) an outbreak in the care home; and (2) the role of the director of public health and the director of adult social services.

Sources of information and support 

This section includes direction to sources, but also the following important message:

If visitors feel a care home is not implementing this guidance properly, in the first instance, they should speak to the care home management. All health and social care service providers must have a complaints procedure that explains how to make a complaint.

If the care is funded or arranged by a local council then they should be contacted about the issue.

If the issue has not been resolved then visitors should complain to the CQC.

Supported living 

The guidance for supported living was updated on 22 November 2021.   In material relating to visits it provides 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, either due to having tested positive for COVID-19 or having travelled to certain countries on the amber and red list. Consideration should also be given to whether the individual be advised to self-isolate for other reasons (that is, following an unplanned hospital stay or other high risk activity)
    • 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:

Testing is not a requirement for visiting and managers should not refuse visits to visitors who have not taken a test unless they are symptomatic. Visitors must not visit if they are required to self-isolate (for example, if they have been notified of a positive COVID-19 test). We recommend visitors participate in testing to reduce risk of introduction of infection through asymptomatically infected people, in particular for higher risk settings with shared living accommodation spaces which have a higher potential for outbreaks.

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 [nb, this has now been withdrawn]

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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