Visitors' protocol - CPA briefing for care providers
- Principles for considering how to enable visitors to care settings
- Policies and procedures
- Essential Family Carers (EFC)
- Mental capacity
- Ability to suspend visiting
- Effective communication
- Learning as the situation develops
- Rights and responsibilities
- Useful links
11 September 2020
This protocol was first published in June 2020 following understandable calls from residents, friends and families, providers and staff to enable visiting to residential homes after a long and protracted period of ‘lockdown’, in line with changes within the wider community. It was produced in response to this request from some very practical help.
The Department of Health and Social Care published guidance on Visiting care homes during coronavirus on 22 July 2020 (updated 31 July 2020)
Many of the issues covered in our original Visitors’ Protocol from June 2020 are now covered by the official government guidance.
We have reviewed and updated our Visitors’ Protocol to reflect the official guidance, where relevant, and to highlight issues to consider or practice which are not covered within Government guidance. We hope that this document will support them in achieving their objectives to open up the home more regularly in a way which is safe and proportionate to their localised understanding of risk.
This protocol aims to provide a set of principles and top tips to help people using care and support to have the opportunity to safely receive visitors during the COVID-19 pandemic, while minimising the risk of its introduction to, or spread within, the care setting.
It is primarily aimed at care settings which cater for older people, including people with dementia, such as residential and nursing homes. However, it will be of help for other care settings such as those supporting working age people with a range of vulnerabilities, including physical, sensory or learning disabilities.
Government has also advised that if a person is clinically extremely vulnerable, then the currently applicable shielding guidance should be followed.
This CPA protocol recognises how difficult it has been for both people using care and those who care for them (loved ones and staff) to restrict visits, and the importance of finding ways to enable visits again in a risk-based, balanced way, and help to reduce the inevitable anxiety experienced by the families and friends of those in care settings as they have been unable to visit them for some time.
This is intended to complement and not to replace Government guidance or the very creative and innovative ways in which care providers have been facilitating ‘virtual’ visits, connecting people via technology to keep in touch, while acknowledging that these have, understandably, been more effective for some groups than others.
The protocol is intended to help during the COVID-19 outbreak, which is anticipated to last for a sustained period, compared to the usual period for other infectious outbreaks. As we see other parts of our community experiencing a degree of easement of the lockdown rules in England, it is important to recognise that for those in residential care settings, there is a need to balance the continued management of COVID-19 risk, with a cautious approach to enabling the opportunity to receive visitors.
Human rights recognise that all people living in care settings have the right to freedom of movement and association, including the right for residents to see their families. This protocol seeks to balance the rights of an individual with the rights of the others within the care setting (residents and staff) and the duties and responsibilities of the care provider.
For many people living in care settings, it is very important that they are able to experience ‘in person’ visits; especially, for example, those with cognitive impairment or dementia whose understanding of the current situation may be limited and who may be significantly affected by the absence of visits, with a deterioration in their overall health and wellbeing. Levels of anxiety and distress resulting from the absence of visits may be increased, while nutrition and hydration may be decreased as often their visitors play an important role in supporting these daily routines in the care setting. People with communication difficulties are another group for whom ‘in person’ visits are key as ‘virtual visits’ can be very challenging.
Thinking about people in care settings more broadly, there is good international evidence that lockdowns are resulting in mental and physical deterioration of residents. Comas-Herrera tells us:
“Family visitors play a large role in the wellbeing and care of care home residents, providing not just love and company, but often help residents with feeding, grooming and recreation. They also play a role in advocacy and timely detection of changes in health of residents. It is likely that without visitors and excursions, and with spatial distancing reducing group activities, residents will feel even more lonely and bored. These feelings might be expressed through aggressive or agitated behaviour or social withdrawal and apathy , which might be treated with psychotropics if staff are not able to manage. Limited opportunities for physical activity may also result in loss of muscle mass and strength, this deconditioning occurs within a few days of hospitalisation in frail older people . Limited opportunities for cognitive stimulation and activity may result in greater cognitive decline in people with dementia .”
Many of those who are living in care settings - such as care homes and nursing homes - are at higher risk of catching COVID-19 and of having poorer outcomes due to co-morbidities, and many will be shielding. The approach to enabling visitors has to be based on the circumstances of the individual care setting (including both residents and staff), the individual needs of the residents within that setting, and the external COVID-19 environment around that care setting.
There are a range of responsibilities on, and expectation of, visitors to care settings which the care provider will need to be clearly set out in any visiting policy.
Given the uncertainty about the future progress of COVID-19 and difference in local transmission rates, providers and the whole care home community will be working in a dynamic situation that will require constant vigilance.
The Government guidance states:
“This process of considering visitors should be led by the relevant local director of public health, who should give a regular professional assessment of whether visiting is likely to be appropriate within their local authority, taking into account the wider risk environment.
To limit risk, where visits do go ahead, this should be limited to a single constant visitor, per resident, wherever possible. This is in order to limit the overall numbers of visitors to the care home and the consequent risk of infection.
Prior to visits being allowed in care homes in a local authority area, the director of public health will assess the suitability of a specified level of visiting guidance for that area taking into account relevant infection and growth rates (see section 1).
Routine awareness of this advised visiting guidance, and any future updates, should be communicated to local Care Provider Associations, local commissioners of care homes, the clinical commissioning group (CCG) infection-control lead and the Public Health England (PHE) local health protection team (HPT). The local outbreak board should also be informed, and the board should proactively keep the advice under review.
The director of public health may action these communications themself or formally request another organisation or individual to act on their behalf.
Where, for whatever reason and at any time, an individual or group of care homes is/are considered to need to restrict visiting, either temporarily or permanently, the director of public health should communicate this advice in writing to commissioners of all the relevant care homes, or in the absence of a commissioner, direct to the registered manager as quickly as possible.”
Principles for considering how to enable visitors to care settings§
Care providers should take a dynamic risk-based approach to how they facilitate and manage visits to care settings, which will need to consider the safety of all their residents, staff and visitors and minimise the risk of any COVID-19 infection.
This will have to balance the risk of harm to residents not having visits, with the risk of harm to residents, staff and visitors. Care providers will need to ensure they take a person centred approach to their visiting policy, taking account of individual needs and capabilities.
Types of visits
Visits may occur in a number of ways:
- Window visits: This will need safe ground floor window access for both residents and their visitors and the relevant social distancing and PPE measures will need to be observed.
- Garden visits: Relevant PPE measures and social distancing will apply. Independent access to the garden will be needed to avoid visitors moving through the care setting to the garden. Providers will need to consider how to facilitate garden visits in different weather conditions, how to ensure cleaning of areas and any items used between visits and keep everyone safe, whatever the weather.
- Drive through visits: These are facilitated visits in the car parks of homes. Again, any relevant PPE measures and social distancing will apply.
- Designated areas within a care setting where settings allow for this: depending on the physical layout of the care setting, it may be possible to enable visits to an identified location inside the care home reserved for this purpose, that facilitates good ventilation, social distancing, ease of access by residents, and limits visitor journeys through the residential areas. An example might include the use of a conservatory as a designated visiting area.
- In-room visits: These visits may continue to be facilitated as appropriate, in line with national guidance in relation to essential / end of life visits to ensure the person can die with dignity and comfort, taking into account their physical, emotional, social and spiritual support needs.
The range of visits made available will be negotiated between the care providers, their residents, their staff and their visitors. It may be possible for residents and visitors to have visits in a variety of these forms, as circumstance allow.
Policies and procedures§
Care providers should work closely with their staff teams and care managers to provide appropriate support, policies and procedures to enable staff to facilitate visits safely and in line with all the relevant guidance.
Care providers may wish to consider developing a short individual visiting plan for each resident (My Visiting Plan) with the overall care plan, tailored to their visiting wishes and preferences, taking account of their individual needs and capabilities and the circumstances of the family/ friends who the resident would like to be able to visit them.
The Government guidance states: “Where care homes are proposing to take a bespoke approach to a specific resident, it should seek to engage family or other likely visitors, any ‘residents and relatives’ committee, and the resident to the fullest extent possible in this decision.”
Care providers will want to carefully regulate and limit the number of visitors initially in order to minimise the risk of the introduction of COVID-19. Government guidance says the risk assessment should, amongst other things:
“consider limiting the numbers of visitors to a single constant visitor per resident, wherever possible. This, for example, means the same family member visiting each time to limit the number of different individuals coming into contact. This is in order to limit the overall number of visitors to the care home and/or to the individual, and the consequent risk of infection.”
This individual should be identified by the resident/ person receiving care, or in discussion with the relevant person with decision making authority of the resident if the resident cannot make that choice.
Government guidance currently does not mention children, but it does recommend limiting visitors to one constant visitor. In practice, care homes have not found a way to be able to accommodate requests for children to visit because there are so many potential complexities in managing visits by children, depending on age and behaviour. Care homes need to be fair and risk based in based in their approach. Care homes can consider alternatives to visits in person for children.
Visits between residents and their visitors must operate fully in line with the latest infection prevention and control guidance including provisions relating to the use of designated areas for visits and the use of social distancing practices, good hand hygiene, use of PPE for visitors and residents.
Visits will need to be booked in advance for a specific day, time and length of visit, to enable visiting to be re-established within the setting. Visitors must check in with the care provider on the day prior to their visit, just in case the situation in the care setting has changed.
Providers may wish to create a ‘Responsible Visitor Code’ which sets out a range of responsibilities that visitors must abide by prior to and during any visit.
The code could state that visitors must:
- book visits in advance for a specific day, time and length of visit
- check in with the care provider on the day prior to their visit, to ensure the situation in the service has not changed
- be free of any COVID-19 symptoms for at least 10 days prior to the visit, as per Government guidance
- not be unwell on the day of their visits
- not be self-isolating as a result of advice from NHS Test and trace
- provide the necessary information required by the provider at the visits (e.g. honest response to screening requirements about COVID-19 risk factors, compliance with NHS Test and Trace arrangements)
- comply with the infection prevention and control measures, including a temperature test, mandatory hand hygiene, the use of PPE as required and social distancing requirements, remaining in the designated visiting area
- ensure that any gifts brought to give to the individual they are visiting can be sanitised, in line with relevant infection prevention and control (IPC) guidance.
Care providers will discuss with potential visitors the best way to get to and from the home. Wherever possible, visitors should a try to walk or travel by car and avoid public transport when visiting the home, in line with the latest government advice on travel during COVID-19.
Essential Family Carers (EFC)
Many family members and friends of care home residents provide essential day-to-day support to help maintain their physical and mental wellbeing. That may include help with eating, drinking, cleaning, or keeping in touch with others.
Some care providers have introduced an Essential Family Carers visiting scheme which, when in line with Government and the local Director of Public Health guidance, can enable EFC support to be reintroduced.
Care home group, Methodist Homes (MHA), define an Essential Family Carer (EFC) as:
“A resident’s family member or friend whose care for a resident is an essential element of maintaining their mental or physical health. Without this input a resident is likely to experience significant distress or continued distress. Although we have used the word Family, we recognise that you may be a resident’s friend and not a family member. Also, we acknowledge that you may not see yourself as a ‘carer’ but as a partner or a supporter of your relative. We chose the term after consultation with a group of resident’s family members and John’s Campaign.”
Care homes may want to develop a similar arrangement.
Care homes should consider:
- Can the task be carried out by a care worker, rather than an EFC?
- What are the residents’ preferences?
- Does the resident have specific needs/characteristics that mean they reply heavily on an EFC to provide support or advocacy (e.g. cultural, religious, gender or sexuality issues)?
- Is the resident unable to maintain relationships through other arrangements, such as outdoor visits or through technology?
- What is the impact on the resident of the lack of regular contact with thie eFC?
If an EFC is identified, care homes may wish to put in special arrangements over and above those required for other visitors. For example, they may require that EFCs must:
- have a negative COVID-19 test within the last week prior to a visit (with appropriate paperwork to confirm this)
- confirm that they are willing to comply with the homes infection control policy
- allow the care home to retain contact details, in case they need to share these with the NHS Test and Trace scheme
- limit visits to a short slot once per week.
For more ideas, see MHA’s More than just a visitor: A guide for Essential Family Carers.
In relation to volunteers, Government guidance says that:
“Where volunteers usually support residents the provider or manager should carefully consider whether their support is more aligned to that of a staff member or a regular visitor and apply the appropriate oversight and infection-control procedures.”
Government guidance states that:
“Providers must consider the rights of residents who may lack the relevant mental capacity needed to make particular decisions and, where appropriate, their advocates or those with power of attorney should be consulted. 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.
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. The government has published advice on caring for residents without relevant mental capacity, and on the MCA and Deprivation of Liberty Safeguards (DoLS), during the pandemic.
Regard should be given to the ethical framework for adult social care, and the wellbeing duty in section 1 of the Care Act 2014. Where the individual has a social worker or other professional involved, they can support the provider in helping consider the risk assessment.”
Ability to suspend visiting
Government guidance says that the “… process of considering visitors should be led by the relevant local director of public health, who should give a regular professional assessment of whether visiting is likely to be appropriate within their local authority, taking into account the wider risk environment.”
In the event of any suspected or actual outbreak of COVID-19, or a suspected or known case of COVID-19 within a home, visitor restrictions may need to be immediately implemented which suspend some of these enabling approaches and will include exclusion of any non–essential visitors. This should be implemented in a transparent manner with open and clear communication to residents and relevant family members.
Care providers will vary their own responses to enabling visits in person to care settings as OVID-19 risks change within their local community, using their dynamic risk-based approach.
Care providers will ensure that they communicate effectively with relatives and other key stakeholders in an open and transparent way about their approach to visiting, in line with the recent joint statement: Keeping Connected: transparency.
Learning as the situation develops
Care providers will be able to review their visiting policies as they learn from their implementation of opening up to visitors and as the wider COVID-19 situation and guidance/ advice evolves.
Suggestions for future consideration from consultees of family representatives on this protocol include: exploring ways in which children may be enabled to visit safely and how a potential ‘staff support volunteer role’ may be possible to enable those relatives who used to visit regularly and spend a lot of time at the care setting and assist with meals/ other activities to return in the longer term.
Rights and responsibilities§
This protocol includes a set of rights and responsibilities for both care providers and visitors which put the welfare and wellbeing of residents/ people receiving care at the heart of the approach to developing their visiting policies.
Care providers have the right to:
Visitors have the right to:
Mitigate risk of infection by refusing entry to their home to anyone, or requesting that a person leave the premises, for any justifiable reason consistent with this protocol.
Access care homes in accordance with the entry requirements set out in the visiting policy of the care setting.
Consider increased visitor restrictions when an outbreak (including non-COVID-19) occurs within the home, or declared outbreak / clusters have occurred within the home’s local area or if there are other extraordinary circumstances that require it, and usage of such circumstances will be closely monitored.
Be notified by timely and regular updates and information about what is happening in the home, in relation to visiting and local COVID-19 prevalence and transmission risk.
Be provided and supported with additional ways to connect such as video conference or telephone calls in addition to a limited number of in-person visits.
Care providers have a responsibility to:
Visitors have a responsibility to:
Follow Government and local Director of Public Health guidance, including guidance on visitors.
Provide a clear policy and information on how they will facilitate visitors, using a dynamic risk-based approach, and make this publicly available as needed.
Follow the home’s visiting policy and Visitor Code, including booking in advance.
Provide clear information about how the visit will work and the infection control measures that must be followed.
Not to visit when unwell or displaying any signs of a cold/flu, respiratory or COVID-19 symptoms.
Appropriately support staff in order to facilitate visits including written processes and procedures.
Respond truthfully to COVID-19 screening questions asked by staff and to sign the checklist / visitor.
Treat all visitors with respect and courtesy, and to provide clear instructions about the visiting policy
Treat all staff with respect and courtesy, and to follow their instructions on the visitor policy.
Proactive communication with residents and families where an outbreak occurs, and the impact on the visiting policy.
Follow visiting requirements including, infection and prevention control measures such as washing hands, use of visiting windows, remaining indesignated areas and social distancing requirements – as directed by the care home staff, and provision of contact details to support NHS Test and Trace – and that failure to do so may affect the future ability to visit.
The CPA assumes no responsibility or liability for any errors or omissions in the publication of this communication. The information contained in this update is provided on an “as is” basis with no guarantees of completeness, accuracy, usefulness or timeliness. It does not constitute legal advice.