Guidance

Visiting care homes during COVID-19

Updated 1 December 2020

Applies to: England

Executive summary

This guidance applies from 2 December 2020 and supersedes previous guidance on visiting policies for care homes.

Visiting is a central part of care home life. It is crucially important for maintaining health and wellbeing and quality of life for residents. Visiting is also vital for family and friends to maintain contact and life-long relationships with their loved ones and contribute to their support and care (often as essential carers).

Welcoming people into care homes from the community inevitably brings infection risk. But that is a risk that care homes can mitigate. It is a risk that should be balanced against the importance of visiting and the benefits it brings to care home residents and their families.

Visiting should be supported and enabled wherever it is possible to do so safely – in line with this guidance and within a care home environment that takes proportionate steps to manage risks.

This means finding the right balance between the benefits of visiting on wellbeing and quality of life, and the risk of transmission of COVID-19 to social care staff and clinically vulnerable residents.

We are distributing rapid (lateral flow) tests to care homes across the country to be used for visitors. Care Quality Commission (CQC) registered care homes will receive these tests during December and have sufficient quantities to test up to 2 visitors per resident, twice a week by Christmas. Visitors will need to arrange visiting with the care home in advance, and will need to be mindful of the additional workload for the care home and that the care home will need to make their own assessments and may develop further policies to ensure the safety of the residents they care for and their staff.

While rapid testing can reduce the risks around visiting it does not completely remove the risk of infection. In addition to using testing, care homes must use robust infection prevention and control (IPC) measures, visitors must continue to wear the appropriate personal protective equipment (PPE) (as described below), observe social distancing in general when in the care home and good hand hygiene, and follow any guidance the care home itself provides on physical contact with the person they are visiting.

This guidance has been developed for the purpose of supporting local system leaders, providers, staff, and families to plan and carry out visits that provide meaningful contact as safely as possible.

Each care home is unique in its physical layout, surrounding environment and facilities. Residents vary in their needs, health and current wellbeing. Care home managers are best placed to decide how visits should happen in their own setting in a way that meets the needs of their residents both individually and collectively.

The individual resident, their views, their needs and wellbeing should be considered for decisions about visiting, while 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.

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 DHSC ethical framework for adult social care.

We recognise how important visiting is as residents approach the end of their lives. As has been the case throughout the pandemic response, visits in exceptional circumstances such as end of life should continue in all circumstances.

Overview of visiting practice supported by this guidance

Key message

Each care home (the registered manager) is responsible for setting the visiting policy in that home. They should do so on the basis of a dynamic risk assessment taking into consideration the needs of individuals within their home and with regard to the advice of the local Director of Public Health (DPH).

All care homes – regardless of Tier – and except in the event of an active outbreak – should seek to enable:

• indoor visits where the visitor has been tested and returned a negative result – see section 2.1 below

• outdoor visiting and ‘screened’ visits – see section 2.3 below

Visits in exceptional circumstances including end of life should always be enabled – see section 2.4 below

In all cases it is essential that visiting happens within a wider care home environment of robust Infection Prevention and Control (IPC) measures, including ensuring that visitors follow (and are supported to follow) good practice with social distancing, hand hygiene and Personal Protective Equipment (PPE) use.

In the event of an outbreak in a care home, the home should immediately stop visiting (except in exceptional circumstances such as end of life) to protect vulnerable residents, staff and visitors (see section 1.4 below)

1. Developing the visiting policy in the care home

1.1 Advice for providers when establishing their visiting policy

Key message

Providers should facilitate visiting as described in this guidance wherever it is possible to do so in a risk-managed way and in line with the principles set out below.

Providers should develop a dynamic risk assessment to help them decide how to provide the visiting opportunities outlined in this guidance, in a way that takes account of the individual needs of their residents, and the physical and other features unique to the care home.

Providers are best placed to design individual visiting arrangements that take account of the needs of their residents and what is possible within the layout and facilities within the home. In this context, the provider must develop a dynamic risk assessment that assesses how the care home can best manage visits safely, and how this is delivered.

This dynamic risk assessment should consider relevant factors relating to the rights and wellbeing of the residents. It may be appropriate or necessary for providers to apply different rules for different residents or categories of resident, based on an assessment of risk of contracting COVID-19 in relation to such residents, as well as the potential benefits of visits to them. This is further explained in the advice for providers when taking visiting decisions for particular residents or groups of residents section below.

The risk assessment should also consider factors relating to the layout, facilities and other issues around the care home – to help determine:

• the rooms in which visiting will happen, where and how visitors might be received on arrival at the home to avoid mingling with other visitors, staff or residents etc

• how the testing arrangements described in section 2.1 below will operate

• the precautions that will be taken to prevent infection during visits (including PPE use and hand washing)

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

Key message

The local DPH and director of adult social services (DASS) have an important role in supporting care homes to ensure visiting happens safely, unless there is good evidence to take a more restrictive approach in a particular care home.

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.

The default position set out in this guidance is that visits 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 outbreak 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 the local outbreak plan (overseen by the DPH) includes care homes. Local authorities may also have powers to issue directions to homes to close to visiting, or to take further specific steps.

The DPH may consider it appropriate to provide advice for specific care homes, or for smaller geographic 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. But the DPH may also provide advice to a specific care home, where they are confident that the IPC measures and other arrangements in that home make it appropriate for it to allow more visiting opportunities than the generic advice set out in this guidance.

Conversely, they may give directions to a specific home about steps they are required to take in order 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 2020 or a Direction pursuant to the Coronavirus Act 2020.

1.3 Advice for providers when taking visiting decisions for particular residents or groups of residents

Key message

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

Some residents will have particular needs (for example, those who are unable to leave their rooms, those living with dementia or those who may lack relevant mental capacity) which will make COVID-secure visits challenging. If so, providers should work with the resident, their family/friends and any volunteers to develop a tailored visiting policy within the principles outlined.

Providers must consider the rights of residents who may lack the relevant mental capacity needed to make particular decisions. 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 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.

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.

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.

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.

1.4 In the event of an outbreak in the care home

In the event of an outbreak in a care home, the home should immediately stop visiting (except in exceptional circumstances such as end of life) to protect vulnerable residents, staff and visitors. There may be local policy and outbreak management arrangements, which will be important to follow. These restrictions should continue until the outbreak is confirmed as over. At that point visiting may resume with the usual infection prevention and control measures and any enhancements required due to any risks identified following the recent outbreak.

2. Delivering safe visiting

2.1 Indoor visiting supported by testing

Key message

Testing is one way of reducing the risk of visiting a care home, but it does not mean there is no longer any risk. Every visitor must return a negative test before each visit.

If a visitor has a negative test, is wearing appropriate PPE, and following other infection control measures then it may be possible for visitors to have physical contact with their loved one, such as providing personal care, holding hands and a hug, although contact should be limited to reduce the risk of transmission which will generally be increased by very close contact.

Care home managers should make clear that testing does not completely remove the risk of infection associated with visiting; and that it is essential that the visitor wears appropriate PPE (as defined in the guidance referred to below) during visits to a care home; observe social distancing in general, follow good hygiene – and that the care home also follows robust IPC.

CQC-registered care homes will receive these tests during December and have sufficient quantities to test 2 visitors per resident, twice a week. Lateral flow devices (LFD) are being provided for this purpose, where the results are available quickly so that the visitor will take the test on arrival, and the visit can only take place provided there is a negative test result.

Visitor numbers should be limited to a maximum of 2 constant visitors 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 disease transmission from multiple different routes.

Before receiving and testing visitors, it is important that care providers consider the practicalities of implementing a visitor testing regime and put in place relevant safeguards. Further Information detailing the practicalities of administering tests and recording results will be available online shortly.

Testing area

Care home managers have discretion to set up their own testing areas with clinical guidance. Care home managers should ensure the testing area has enough space to allow visitors to maintain social distancing before, during and after the test, including a waiting area and a one-way system. The area should comply with fire safety regulations that govern deployment sites and have hard, non-porous flooring that can withstand chlorine cleaning agents. Visitors should have ready access to hand hygiene and the area should be well ventilated with fresh air, either by appropriate ventilation systems or by opening windows and doors. Care managers should also consider storage implications for testing.

Preparing and communicating with visitors

Care home managers should communicate to visitors the purpose of testing – that it does not completely remove the risk of infection in relation to visiting. It is important that care homes are clear to visitors about the expectations placed upon visitors participating in tested visiting (ie in respect of PPE use, social distancing, hand hygiene, any physical contact, actions in the event of a positive test).

These expectations include the requirement for a visitor who tests positive to immediately self-isolate and complete a confirmatory PCR test which should be provided to them by the care home. If the confirmatory PCR comes back positive, their household must also self-isolate and contacts may also need to self-isolate in line with current government guidance. Care homes should obtain consent from visitors prior to participating in testing.

2.2 Interim measures for indoor visiting without testing in Tier 1

Key message

Indoor visiting without testing may only go ahead in Tier 1 areas where visitor testing is not yet available in the particular care home – indoor visits may go ahead provided they are limited to 2 people (one preferably), with social distancing, no physical contact, PPE use and good hand hygiene observed at all times.

Indoor visiting in the absence of testing (and without screens between the resident and visitor) may only happen in Tier 1 areas with visitors also from a Tier 1 area. Care homes in Tier 1 areas should still implement visitor testing as rapidly as possible. As soon as visitor testing is available, it is by far the preferable option and should be used.

In the limited instances where indoor visiting takes place without the visitor being tested immediately beforehand, visits should take place in a well-ventilated room, for example with windows and doors open where it is safe to do so.

Providers should consider the use of designated visiting rooms, which are only used by one resident and their visitor at a time and are subject to regular enhanced cleaning.

Any areas used by visitors should be decontaminated several times throughout the day and providers should avoid clutter to aid cleaning.

Visits should be limited to a single constant visitor wherever possible, with a maximum of 2 constant visitors per resident. 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 disease transmission.

Visitors should be supported to ensure that the appropriate PPE is always worn and used correctly, and that they follow good hand hygiene. They should follow guidance on how to work safely in domiciliary care in England to identify the PPE required for their visiting situation.

Visits in these circumstances should be supervised at all times to ensure that social distancing and PPE use is maintained. There should be no physical contact between residents and visitors. This can only be enabled where testing is available for visitors.

2.3 Outdoor visiting and ‘screened’ visits

Key message

These visits can be made available to visitors who have not been tested, in order to provide opportunities for more visitors and greater frequency of visits than the available testing capacity in the care home might enable. Below are the principles providers should follow for these arrangements.

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

Visits should happen in the open air wherever possible, recognising that for many residents and visitors this will not be appropriate in the winter (this might include under a cover such as an awning, gazebo, open-sided marquee etc.) For these visits:

• the visitor and resident must remain at least 2 metres apart at all times

• the visit can take place at a window

Some providers have used temporary outdoor structures – sometimes referred to as ‘visiting pods’ – which are enclosed to some degree but are still outside the main building of the home. These can be used. Where this is not possible, a dedicated room such as a conservatory (ie wherever possible, a room that can be entered directly from outside) can be used. In both of these cases, providers must ensure that:

• the visiting space is used by only one resident and visiting party at a time, and is subject to regular enhanced cleaning between each visit

• the visitor enters the space from outside wherever possible

• where there is a single access point to the space, the resident and visitor enter the space at different times to ensure that safe distancing and seating arrangements can be maintained effectively

• there is a substantial screen between the resident and visitor, designed to reduce the risk of viral transmission

• there is good ventilation for spaces used (for example, including keeping doors and windows open where safe to do so and using ventilation systems at high rates but only where these circulate fresh air)

• consider the use of speakers, or assisted hearing devices (both personal and environmental) where these will aid communication. This will also avoid the need to raise voices and therefore transmission risk

In all cases:

• visitor numbers should be limited to a single constant visitor wherever possible, with an absolute maximum of 2 constant visitors per resident. 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 disease transmission from multiple different routes

• appropriate PPE must be used throughout the visit, and around the care home building and grounds

• social distancing (between visitors and residents, staff, and visitors from other households) must be maintained at all times – during the visit, and around the care home building and grounds

• high quality IPC practice must be maintained throughout the visit and through the wider care home environment. (See section below on infection control precautions in the wider care home environment)

• visiting spaces must be used by only one resident and visiting party at a time, and between visits there must be appropriate cleaning and an appropriate time interval

As set out above, decisions on visiting policies require a risk assessment. Some of the arrangements that providers make may well include visitors using the grounds and layout of the care home in a different way to usual (for example, entering the garden or grounds through a different entrance or sitting/standing in outdoor spaces not usually used in that way). Providers should therefore include a consideration of these factors – both in terms of the practical safety of visitors and residents (which may be exacerbated by inclement weather or icy conditions), and infection risks arising – in their overall risk assessment.

2.4 Exceptional circumstances such as end of life

Key message

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 more deliberately, with the assumption that visiting will be enabled to happen not just towards the very end of life.

End-of-life care (for residents in care homes) means early identification of those who are in their last year of life and offering them the support to live as well as possible and to then die with dignity. NHS guidance on end of life care is available to support this process, as well as advice from the British Geriatric Society. There is a role for the care home staff to support residents with end-of-life care and visiting is a large factor in this.

The Enhanced Health in Care Homes service provides a framework for the support from General Practice, the care home clinical lead and multidisciplinary team (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, the relatives and the care home staff through the weekly home care round. This British Geriatric Society advice can support communication.

Care homes are responsible for ensuring that the right visiting arrangements are in place for each resident, facilitating visiting as much as possible and appropriate with an individual’s situation, but made as safely as possible including the appropriate infection prevention control measures.

As a resident approaches the last months, weeks and days of life it becomes important to communicate well to enable good and timely decisions around care and especially important to allow visits to residents. 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.

2.5 Infection control precautions and the wider care home environment

Key message

It is essential that visits take place in the context of robust practices for infection prevention and control throughout the care home. This is an essential part of ensuring that visits – in all of the situations described above – can happen as safely as possible.

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 homes wider infection prevention and control practice. The homes should ensure that these are communicated in a clear and accessible way.

The CQC will include adherence to infection control measures for visitors as part of their infection prevention control inspections. It is vital that providers are meeting required standards.

The following considerations and precautions should be taken into account when visitors are visiting residents of the home:

• visitors must follow any guidance, procedures or protocols put in place by the care provider to ensure compliance with infection prevention control. Therefore, copies of the guidance, procedures and protocols should at least be available to be read by visitors on arrival

• visitors should be supported to ensure that the appropriate PPE is always worn and used correctly, and they follow good hand hygiene. They should follow the guidance on how to work safely in domiciliary care in England^{[footnote 1]} to identify the PPE required for their visiting situation. Care homes are being provided with PPE to meet these requirements

• in exceptional circumstances, a very small number of residents may (by nature of their care needs) have great difficulty in accepting staff or visitors wearing masks or face coverings. The severity, intensity and/or frequency of the behaviours of concern may place them, visitors or the supporting staff at risk of harm. A comprehensive risk assessment for each of these people identifying the specific risks for them and others should be undertaken for the person’s care, and this same risk assessment should be applied for people visiting the person. If visors or clear face coverings are available, they can be considered as part of the risk assessment. However, visors will not usually deliver the same protection from aerosol transmission as a close fitting mask. Under no circumstances should this risk assessment be applied to a whole care setting

• 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 the tissues

• visitors should have no contact with other residents and minimal contact with care home staff (less than 15 minutes/2 metres). Where needed, conversations with staff can be arranged over the phone following an in-person visit

All visitors should be screened for symptoms of acute respiratory infection before entering. No one who is currently experiencing, or first experienced, coronavirus symptoms in the last 10 days, should be allowed to enter the premises, nor anyone who is a household contact of a case or who has been advised to self-isolate by NHS Test and Trace, or who is in a relevant quarantine period following return from travel.

Any potential visitor who tests positive should immediately leave the premises and self-isolate. They should be offered a confirmatory PCR test by the care home and their household contacts may also be required to self-isolate in line with current guidance. Screening questions that care homes may wish to ask visitors on arrival are:

• have you been feeling unwell recently?

• have you had recent onset of a new continuous cough?

• do you have a high temperature? A care home may consider providing a temperature check for all visitors to provide confidence to visitors and to staff

• have you noticed a loss of, or change in, normal sense of taste or smell?

• have you had recent contact (in the last 14 days) with anyone with COVID-19 symptoms or someone with confirmed COVID-19. If yes, should you be self-isolating as a family member or as a contact advised to do so by NHS Test and Trace?

• have you returned from an overseas visit recently and are you still in the quarantine period?

Staff should discuss with visitors any items they wish to bring with them on their visit, such as a gift. It will need to be something that can be easily cleaned by the care home to prevent cross contamination. For example, a box of chocolates that could be sanitised with wipes.

Care homes should support NHS Test and Trace by keeping a temporary record (including address and phone number) of current and previous residents, staff and visitors (including the person/people they interact with – for example if a person visits their loved one who is also visited by a chaplain in the course of the visit), as well as keeping track of visitor numbers and staff.

2.6 Communicating with families and visitors

Key message

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.

The care home’s visiting policy should be made available and/or communicated to residents and families, together with any necessary variations to arrangements due to external events. Care homes should also consider what additional communications (including posters, leaflets letters etc.) would help visitors to understand what to expect from visiting – including the length and frequency of visits as well as how they will be conducted.

Advice for residents and families should be set out in the visiting policy of the care home and shared with them. This advice should cover issues such as:

• visitors should be given support on how to prepare for a visit and given tips on how to communicate while wearing a face covering (including a surgical mask if that is the case), for example:

  • speaking loudly and clearly

  • keeping eye contact

  • not wearing hats or anything else that might conceal their face further

  • wearing clothing or their hair in a way that a resident would more likely recognise

• provide reassurance to visitors, including that some people with dementia might struggle at first to remember or recognise them. Care home staff should try to prepare the resident for a visit, perhaps by looking at photographs of the person who is due to visit and talking to them about their relationship

• where indoor visiting is being supported by testing – advice that testing is one way of minimising the risk of visiting a care home. If a visitor has a negative test, is wearing appropriate PPE, and following other infection control measures then it may be possible for visitors to be have physical contact with their loved one, such as providing personal care, holding hands and a hug. However, it is important to understand that all close contact increases risk of transmission. Any potential visitor who tests positive should immediately leave the premises and self-isolate. They should be offered a confirmatory PCR test by the care home and their household contacts may also be required to self-isolate in line with current guidance

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.

Family and friends should be advised that if there is a declared outbreak in a care home then visiting will need to be restricted only to exceptional circumstances such as end of life.

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.

1. The guidance relates to domiciliary care, but is the advice that Public Health England recommend is followed by visitors. ↩