Guidance

[Withdrawn] Guidance on care home visiting

Updated 22 March 2022

This guidance was withdrawn on 1 April 2022

The information in this guidance has been superseded by Infection prevention and control in adult social care: COVID-19 supplement.

Applies to: England

This guidance applies from 22 March 2022 and replaces previous guidance on care home visiting.

This guidance applies to all residential care homes. There is separate guidance for supported living and extra care settings.

There are no nationally set direct restrictions on visiting 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
• isolation on return from some high-risk activities out of the home

This guidance is based on regularly reviewed clinical advice.

This guidance covers:

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

The key things to know about care home visiting are:

• visitors should make arrangements with care homes in advance of the visit, so that care providers can manage the number of people attending at any one time to ensure safe visiting practices can be maintained taking into account the size and layout of the care home
• the duration of visits should not be limited if safe visiting practices can be maintained
• 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 result and report it 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 the additional testing arrangements outlined below
• every care home resident should be supported to have an identified 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 isolation and outbreak, providing the essential care giver does not have COVID-19
• during an outbreak, care providers should also continue to offer visits outdoors, in visiting pods or from behind windows – rooms should be left to ventilate with external doors and windows open between uses wherever possible, while aiming to maintain a comfortable temperature for residents and visitors
• subject to a risk assessment by the health protection team (HPT), outbreak restrictions may be lifted if 10 days have passed since the onset of symptoms in the most recent case, a round of PCR recovery testing of all residents and staff is undertaken, and there are no PCR positive results
• physical contact should be enabled to help health and wellbeing, as long as IPC measures are in place, such as visiting in a ventilated space, using appropriate personal protective equipment (PPE) for the visit, and hand washing before and after visiting – gloves are not needed for handholding and stringent adherence to hand washing is advised
• residents should be supported to undertake visits out of the care home as appropriate, following the reasonable precautions and testing arrangements outlined in this guidance
• all residents should isolate for 10 days (with testing to end isolation sooner) following a high-risk visit out, including an emergency stay in hospital, or if they test positive for COVID-19
• vaccination is one of our best defences to combat 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. The data shows that booster doses are required to provide higher levels of protection against symptomatic infection. 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 and have received their booster. 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 and infections, such as cough, high temperature, diarrhoea or vomiting, they should avoid the care home until at least 5 days after they feel better
• visitors are advised against visiting the care home (for 10 days) 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 lateral flow test result earlier in the day of their visit

1. Visits in all circumstances

1.1 Essential care givers

Key message

All residents should be enabled to have an essential care giver, who should be able to visit more often. Essential care givers will need to be supported to follow the same testing arrangements as care home staff. When essential care givers are providing direct personal care, they should follow the same PPE and infection control arrangements as care home staff.

The essential care giver role is vitally important to supporting residents’ health and wellbeing.

Every resident should be supported to choose an essential care giver to benefit from companionship and additional care and support provided by someone with whom they have a personal relationship.

Essential care givers can visit in periods of outbreak and when their friend or family member in a care home is isolating. If a care home resident has tested positive for COVID-19, essential care giver visits can be made in exceptional circumstances (for example, severe distress or end of life) with appropriate IPC support, and consideration of vulnerability and vaccination status of the essential care giver.

There are exceptional circumstances where someone may need the additional support of more than one essential care giver and this should be considered (for example, if a nominated essential care giver is unwell).

Essential care givers will need to follow the same testing arrangements as staff for both regular asymptomatic testing and in an outbreak. Further information on staff testing regimes can be found in the care home testing guidance.

Essential care givers should read and follow the appropriate guidance for using PPE in the different care scenarios laid out in the guidance on how to work safely in care homes. PPE recommendations are different depending on whether direct personal care or companionship is being provided. More information on how to safely put on and remove PPE can be found in the guidance and visitors should also be encouraged to view the video demonstration. It is sensible for the essential care giver to be supported by an experienced member of staff as they put on and take off the PPE on the first few visits to ensure they are doing so correctly.

Essential care givers should be briefed on the relevant IPC measures in the areas of the care home they will have access to, and reminded of the importance of remaining at least one metre from staff and any other residents they might encounter, though this may differ subject to a local risk assessment.

The care home and essential care giver should also agree any other relevant arrangements – for example, managing immediate visits (if the resident is distressed and the essential care giver is needed urgently to settle them) and communal areas such as staff rest areas that the essential care visitor should not enter.

Clinical care and medical tasks such as the administering of medication and physiotherapy remain the overarching responsibility of the care home.

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.

1.2 End of life visits

Key message

Visits at the end of life should always be supported, including where the resident has COVID-19 following appropriate IPC support, and consideration of vulnerability and vaccination status of the visitors. 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 for visits of this nature should be tested using lateral flow tests. For information on how to test, see the guidance on rapid lateral flow testing in adult social care settings.

End of life care (for residents in care homes) means identifying early 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. There is a role for care home staff to support residents with end of life care, and visiting is an essential factor in this.

The enhanced health in care homes service provides a framework for support from general practice, the care home clinical leads and local multidisciplinary teams (which may include community nurses and professionals as well as specialised palliative care teams).

This support involves early identification, as well as a personalised care and support planning approach with good communication with the individual, their relatives and care home staff through the weekly home care round. The British Geriatric Society advice can support communication.

As a resident approaches the last months, weeks and days of their life, it continues to be important to communicate well to enable good and timely decisions around care. Planning these visiting arrangements should proceed from the assumption that visits are enabled in the final months and weeks of life – not just the final days or hours – albeit recognising that these timelines can be difficult to determine with accuracy.

1.3 Professional visits in the care home

Key message

Health, social care and other professionals need to visit care home residents to provide services. Care homes should facilitate these visits while ensuring necessary testing, IPC and PPE measures are adhered to. The arrangements for visiting professionals differ from those for family and friends visiting the care home.

Visiting professionals will need to have a negative test before visiting. Refer to the guidance on testing for health professional visits for further information on testing requirements (which differ from those outlined for family and friends in this guidance).

During an outbreak, visiting professionals should normally be able to continue to visit, provided they adhere with all necessary IPC precautions.

2. Safe visiting practices

2.1 Infection prevention and control (IPC)

Key message

Providers should facilitate visiting in a way that allows them to manage the risk of COVID-19 and other infections, such as flu, in line with the principles set out below.

It is essential to safe visiting that visiting happens within a wider care home environment of robust IPC. Visitors should make arrangements with the care home before visiting to ensure adequate IPC measures are in place.

The provider’s policy should set out the precautions that will be taken in respect of infection control during visits, placing this within the context of the care home’s wider infection prevention and control practice. Care homes should ensure that these are communicated in a clear and accessible way to visitors.

The Care Quality Commission (CQC) has included adherence to infection control measures for visitors as part of its infection prevention control inspections. It is vital that providers are meeting required standards.

The following precautions should be followed when visitors are inside the care home. All visitors should:

• follow any guidance and procedures put in place by the care provider to ensure compliance with IPC – therefore, copies of the guidance and procedures should at least be available to be read by visitors on arrival
• be reminded that following IPC measures (for example, hand washing) is essential even if PPE is worn, they have been vaccinated and produced a negative test
• be supported therefore to ensure appropriate PPE is always worn and used correctly, and they follow good hand hygiene – care homes are being provided with PPE to meet visiting requirements

Visitors should wear a face mask when visiting the care home, particularly when moving through the care home. COVID-19 spreads through the air by droplets and aerosols that are exhaled from the nose and mouth of an infected person. Face masks reduce the risk of spreading COVID-19, especially when there is close contact between people in enclosed, poorly ventilated and crowded spaces. It is important that face masks fit securely around the face to safely cover the mouth, nose and chin.

We recognise that individual approaches are needed as the wearing of face masks may cause distress to some residents. In these circumstances, face masks may be removed when not in communal areas of the care home. However, other mitigations should be considered, including limiting close contact and increased ventilation (while maintaining a comfortable temperature). Visitors could also consider using a transparent face mask that is compliant with the transparent face mask technical specification. These can be purchased directly from manufacturers and used subject to local risk assessment.

It is important to seek advice and support from the care home management team at an early stage if the measures show signs of causing distress for individual residents. If face masks are to be removed, a comprehensive risk assessment should be undertaken for each resident identifying the specific risks to them, care home staff and visitors to develop appropriate strategies to safely manage those risks. It is important PPE items are not altered in any way as this could reduce their effectiveness in protecting staff or residents.

It is not usually recommended to wear a face mask while undertaking visits outdoors. However, a risk assessment should be undertaken, and mitigations considered if visitors may be in very close contact with someone or if there is likely to be contact with bodily fluids, for example due to someone spitting or coughing.

Visitors should be reminded, and provided 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 tissues.

Visitors should limit contact with other residents and staff, and maintain as much distance as possible. Regular conversations with staff can be arranged over the phone following in-person visits.

Communal areas can be used for visits if there is only one visiting group using the area at a time. Individual groups may wish to remove face masks to share a meal together in communal areas, providing no other people are in the area.

2.2 Risk assessments

Key message

When developing their visiting policies, providers should undertake individual risk assessments to assess the rights and needs of individual residents, as well as any specific vulnerabilities that are outlined in the resident’s care plan, and to consider the role that visiting can play in this.

Providers must develop a risk assessment that assesses how the care home can best manage visits safely, considering:

• the needs of their residents and visitors
• residents’ rights to visits and the important role visitors play in residents’ wellbeing
• what is possible within the layout and facilities within the home to ensure that mixing between visitors is limited as much as possible
• where and how visitors might be received on arrival at the home to avoid mixing with other visitors, staff or residents
• the precautions that will be taken to prevent infection during visits (including PPE use, ventilation, limiting close contact and hand washing)
• legal duties relevant to visiting, including the Care Act 2014, Mental Capacity Act 2005 and Human Rights Act 1998

Residents and their loved ones should always be involved in developing individual risk assessments.

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.

2.3 Testing arrangements

Key message

This guidance applies to family and friends visiting care homes. There is different guidance on testing for professionals visiting care homes.

Before receiving and testing visitors, it is important that care providers consider all the necessary practicalities of implementing a visitor testing regime and put in place relevant safeguards. Further information detailing the practicalities of administering tests and reporting results, including simple guides for visitors, can be found in the guidance on rapid lateral flow testing in adult social care settings. Each pack of tests will also come with instructions.

Testing onsite at the care home is preferable for assurance purposes. Where testing will be fully or partly conducted onsite, care home managers will need to set up a testing area as described in the guidance above. However, recognising that individuals now have access to testing through other routes and visitors may be travelling long distances to visit, care home managers can allow visitors to provide evidence of a recent negative test undertaken through other means, if the test has been taken that same day. Testing arrangements are different for visiting professionals (as outlined in section 1.3).

Medicines and Healthcare products Regulatory Agency (MHRA) rules state that care homes are not able to distribute packs of 25 tests to visitors to self-test.

When considering the most appropriate testing route, managers should consider any additional risks that may arise from testing off-site, as well as the confidence of visitors to carry out tests away from the care home. This may include factors such as:

• visitors inaccurately conducting or reporting lateral flow testing themselves
• the increased risk of visitors needing to take public transport to a testing site, particularly where it is far from the setting, or coming into contact with other people
• the need for visitors to have a mobile phone or email address to receive the result of their test

Where visitors will be self-testing, managers may wish to supervise the first few tests on-site and provide support to ensure visitors are confident conducting the tests at home, and they are being completed and reported satisfactorily.

Wherever the test is conducted, it must be done on the day of the visit. Once the visitor has reported the test, they will receive confirmation of their result by text message (SMS) and email to show proof of result. Visitors should show proof of a negative test result before every visit, such as:

• an email or text from NHS Test and Trace
• a date-stamped photo of the test cartridge itself

If visitors are not able to produce a negative test, they may be asked to reschedule or be prepared to take the test onsite.

Care homes do not need to retain records of proof. All tests done both at the care home and when self-testing at home should be reported to the UON of the care home, and managers should ensure visitors are aware of their UON and the legal duty to report the result. This will support NHS Test and Trace and public health teams to better support care homes to understand the transmission of COVID-19 and prevent outbreaks.

If a visitor tests positive, they should not enter the care home for 10 days.

2.4 Visits out of the care home

Key message

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, for education, to attend work or for a longer visit, including an overnight stay to see family and friends.

All residents (regardless of vaccination status) should not normally need to self-isolate following a visit out, but a risk assessment should be completed with consideration given to:

• the number of people involved in the visit (and whether they are ‘usual contacts’ of the resident or people they do not usually mix with)
• if the vaccination status of those involved in the visit is known or not
• whether those involved in the visit have received a recent negative lateral flow test result
• the characteristics of the setting (for example, enclosed settings would be higher risk than open air settings)

Residents should isolate for a maximum of 10 days from other residents following an emergency stay in hospital (as they are higher risk than an elective admission) or other high-risk visit out. During this period of isolation within the care home, residents may continue to undertake visits out of the care home, if:

• a risk assessment by the care provider shows they can avoid other residents
• they are not visiting another social care setting
• consideration is given to the vulnerability of those they will be visiting

Residents who are able to take lateral flow tests should be able to end isolation as follows. Residents who are:

• vaccinated (with their primary dose and any eligible booster dose) should take a lateral flow test on day 4, 5 and 6, following their return to the care home (day 0), and, if negative, can end isolation
• unvaccinated should take a lateral flow test on day 6, 7 and 8, and, if negative, can end isolation

Residents who are unable to test should isolate for 10 days.

Following elective or emergency hospital stays, if there is an outbreak of an infection that originated in hospital in the part of the hospital where the resident stayed, refer to guidance on admission and care of residents in a care home during COVID-19. Separate guidance is available on planning visits that residents may need to make to a hospital or other healthcare setting.

If a provider is concerned that protocols were not followed or there may have been exposure during a visit to a clinical setting, they should seek advice, if required, from IPC leads within the clinical commissioning group, IPC nurses in the hospital, HPTs or directors of public health.

Other steps to mitigate the risk of an individual resident’s visits out of a care home include:

• where possible, anyone else who the resident meets as part of an indoor visit should undertake a lateral flow test and receive a negative result on the day of the visit – all tests should be reported to the UON of the care home
• following wider guidance on ventilation, limiting close contact, good hand hygiene and respiratory hygiene while people are away from the home
• careful consideration of transport arrangements. If the care home is using its own vehicle then cleaning protocols will need to be in place. If comfortable, the vehicle windows should be opened to aid ventilation
• if the resident is being accompanied by a member of care home staff, a risk assessment should be carried out. This should assess the COVID-19 transmission risk to the care worker arising from any activities during the visit to ensure that the necessary precautions are in place. This may, for example, include if the care worker is likely to undertake direct personal care, as per the how to work safely in domiciliary care and how to work safely in care homes guidance, and therefore whether the care worker requires PPE (above that recommended for individuals in a public place). If necessary, the staff member should take the required additional PPE, as well as the means to safely store or dispose of it, along with a spare replacement face mask, with them when they leave the care home

2.5 Communicating visiting arrangements to residents, families and friends

Key message

It is important that advice and instructions provided by the care home are clearly communicated to reduce risks to visitors and their loved ones as much as possible.

The care home’s visiting policy should be made available and communicated to residents and families, together with any necessary variations to arrangements.

Care homes should also consider what additional communications (including posters, leaflets, letters and so on) would help visitors to understand what to expect from visiting, as well as the different arrangements for visitors and essential care givers.

Visitors should be clear with care homes about the best method of communication for them, and providers should meet these communication preferences.

3. When different visiting arrangements are needed

3.1 Care home outbreaks

An outbreak is defined as 2 or more confirmed cases of COVID-19, or clinically suspected cases of COVID-19 among people in the same specific setting, with the onset of symptoms within 10 days. For more detailed guidance on the definitions of outbreaks please see the COVID-19: epidemiological definitions of outbreaks and clusters in particular settings guidance.

If a care home has an outbreak, this has impacts on visiting. In the event of an outbreak in a care home, the home should stop indoor visiting (except in exceptional circumstances such as end of life). All movements out of a setting should be minimised as far as possible. Essential care givers should be allowed to continue to visit indoors.

In the event of an outbreak, other methods of maintaining contact between residents and their loved ones (who are not essential care givers) should be supported. This could include:

• visits in well-ventilated spaces with substantial screens, visiting pods or from behind windows
• telephone calls
• video calls
• newsletters
• emails, letters, cards or photographs

A risk assessment should consider the impact of the outbreak and capability to facilitate window or other visits without breaching zoning or cohorting of residents and staff. HPTs, local authority directors of public health, clinical commissioning group infection control leads and other partners can provide advice to care homes to help them with such a risk assessment.

Outbreak restrictions will be in place for different lengths of time, depending on the characteristics of the outbreak and the results of outbreak testing.

If the first and second rounds of outbreak PCR testing do not detect any further cases in residents or staff, then outbreak control restrictions may be lifted following a risk assessment by the HPT. This may mean that outbreak measures may only be in place for about 7 days (depending on PCR turnaround times), if there is no evidence of further transmission within the care home.

Otherwise, outbreak recovery testing should be undertaken when there have been 10 days with no new cases. If no new cases are found, outbreak restrictions can then be lifted.

If the outbreak involves a particular variant which requires additional mitigations (this does not include Alpha, Delta or Omicron), outbreak recovery testing should take place once there have been 28 days with no new cases, rather than 10 days.

For more detailed information on outbreak management, see ‘Reporting of COVID-19 cases, caring for residents with COVID-19 and outbreak management’ in Admission and care of residents in a care home during COVID-19. See also guidance on Coronavirus (COVID-19) testing in adult care homes.

3.2 Role of the director of public health and the director of adult social services

Key message

The local director of public health (DPH) and director of adult social services (DASS) have an important role in supporting care homes to ensure visiting happens safely. They should support the visiting arrangements set out in this guidance, unless there is good evidence to take a more restrictive approach in an individual care home for a limited period.

While frameworks and advice developed by the DPH and covering the local population may be helpful, these should recognise different circumstances in individual homes and variations in infection rates in different areas within the local authority. It is important that any frameworks and advice enable care homes to exercise discretion based on their own circumstances.

Blanket visiting bans covering whole local authority areas are not appropriate.

The default position is that visits of all kinds should be supported and enabled wherever it is safe to do so. The local DPH and DASS have an important role in ensuring that can happen across their local area and may provide advice to care homes accordingly. This may be through a dedicated care home outbreaks management team or group, often in partnership with local social care commissioners. The DPH should work with the local DASS in developing and communicating their advice to care homes.

The role of the DPH includes formally leading efforts to suppress and manage outbreaks, and ensuring the local outbreak plan (overseen by the DPH) includes care homes. Local authorities may also have powers to issue directions to care homes to close to visiting, or to take further specific steps. However, care should be taken to ensure such directions are dynamic and applied proportionately across a local authority area.

The DPH may consider it appropriate to provide advice for specific care homes, or for areas within the local authority where differences in infection rates or other factors make this appropriate. This may take the form of a framework and guidance rather than individual home-by-home advice.

The DPH may give directions to a specific home about steps they are required to take to allow visiting safely. This may at times take the form of a notice or direction pursuant to the Public Health (Control of Disease) Act 1984. It may also take the form of a direction pursuant to Schedule 22 of the Coronavirus Act 2020.

Conversely, the DPH may also provide advice to a specific care home, where he or she is confident that the IPC measures and other arrangements in that home make it appropriate for it to allow more visiting opportunities. This should be shared in a clear and simple way with residents and loved ones.

4. Sources of support and information

Key message

If care providers have any queries regarding visiting, a range of additional support is available.

Providers may wish to seek advice from their local DPH or DASS.

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 government has produced infographics that may be useful in supporting visitors to follow good practice with hand hygiene (hand washing or using hand sanitiser) and putting on and taking off PPE.

Providers should also have regard to the Department of Health and Social Care (DHSC) ethical framework for adult social care.

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 contact the CQC to give feedback on their care.