Guidance

Guidance on care home visiting

Updated 17 June 2021

Applies to: England

This guidance applies from 21 June 2021 and replaces previous guidance on care home visiting. This guidance applies to residential care homes and care home residents of all ages. There is separate guidance for supported living and extra care settings.

The measures described in this guidance relate to visits with friends and family that take place within care home premises. Guidance relating to visits where the resident leaves the care home premises are described in our guidance on visits out of care homes.

Visiting is a central part of care home life. It is crucially important for maintaining the health, wellbeing and quality of life of 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.

This guidance sets out the government’s advice to support safe visiting:

• every care home resident can nominate up to 5 ‘named visitors’ who will be able to enter the care home for regular visits (and will be able to visit together or separately as preferred)
• the 5 named visitors may include an essential care giver (where residents have one). Babies and preschool-aged children do not count towards the total of 5 (provided no individual visits breach national restrictions on indoor gatherings)
• to reduce the risk of infection, residents can have no more than 2 visitors at a time or over the course of one day (essential care givers are exempt from – and so not included in – this daily limit)
• every care home resident can choose to nominate an essential care giver who may visit the home to attend to essential care needs. The essential care giver should be enabled to visit in all circumstances, including if the care home is in outbreak (but not if the essential care giver or resident are COVID-positive)
• named visitors and residents are advised to keep physical contact to a minimum (excluding essential care givers). Physical contact like handholding is acceptable if hand washing protocols are followed. Close personal contact such as hugging presents higher risks but will be safer if it is between people who are double vaccinated, without face-to-face contact, and there is brief contact only
• national restrictions on indoor gatherings should be followed. Find out more about what you can and cannot do
• care homes can also continue to offer visits to other friends or family members through arrangements such as outdoor visiting, rooms with substantial screens, visiting pods, or from behind windows

Read a summary of the guidance for visitors.

Care home visiting should be supported and enabled wherever it is possible to do so safely – supported by this guidance and within an environment that is set up to manage risks. All visitors also have an important role to play – helping to keep their loved ones, other residents and staff safe by carefully following the policies described in this guidance, and the practical arrangements that care homes put in place, such as internal risk assessment and infection prevention and control protocols. Local system leaders such as the directors of public health (DPH) and directors of adult social services (DASS) also have a key role in this partnership to support visiting.

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

In the face of new variants of the virus, we need to remain alert to ensure we protect those most at risk in care homes while ensuring indoor visits can go ahead.

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

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

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

If the provider or manager has any queries regarding visiting, a range of additional support is available. Providers may wish to seek advice from their local Director of Public Health or Director of Adult Social Services, both of whom have an important role to play in supporting visiting, and in supporting the care home to deliver the visits described in this guidance. Additionally, care homes may wish to make use of the resources provided by Care England and Partners in Care, a coalition of providers, relatives and residents organisations facilitated by the National Care Forum.

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

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

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

We recognise how important visiting is to residents who are approaching the end of their lives (see section 2.4 below) and this should not just mean at the very end of one’s life. Families and residents should be supported to plan end-of-life visits, with the assumption that visiting will be enabled to happen not just towards the very end of life, and that discussion with the family should happen in good time. As has been the case throughout the pandemic response, visits in exceptional circumstances such as end of life should continue in all circumstances (including in the event of an outbreak).

Visiting is just as important for people living in supported living and extra care settings. This guidance does not directly apply to those settings – the diversity of the settings and the needs of those who live in them means this guidance will not be suitable in all cases. However, supported living and extra care managers may wish to use the guidance to help them support safe visiting in the services they manage.

To support visiting, additional rapid lateral flow testing has also been provided for visitors in supported living and extra care settings where staff are currently eligible for testing. Read guidance on visiting in supported living.

Overview of visiting practice supported by this guidance

Key message

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

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

All care homes, except in the event of an active outbreak, should seek to enable:

• indoor visiting by up to 5 ‘named visitors’ for each resident. These visitors will need to comply with the arrangements for testing, PPE and social distancing set out in section 2.1 below

• every care home resident to choose to nominate an essential care giver who may visit the home to attend to essential care needs. The essential care giver should be enabled to visit in all circumstances, including if the care home is in outbreak. Essential care givers will need to be supported to follow the same testing arrangements, and the same PPE and infection control arrangements, as care home staff. See section 2.2 below. Further information on PPE and infection control can be found in the guidance on how to work safely in care homes

• the 5 named visitors may include an essential care giver (where residents have one) but excludes babies and preschool-aged children (as long as this does not breach national restrictions on indoor gatherings)

• to reduce the risk of infection, residents can have no more than 2 visitors at a time or over the course of one day (essential care givers are exempt from this daily limit)

• opportunities for every resident to see more people than just their named visitors, by enabling 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. The government has produced infographics which 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.

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 – and for essential care givers) 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. Any risk assessment should follow the CQC regulatory framework around providing person centred care. It may also be appropriate or necessary for providers to apply different rules for different residents 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. The risk assessment should consider the need to enable essential care giver visits described in section 2.2 below. 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:

• where visiting will happen – including the rooms or outdoor spaces 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

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

Care home managers should share the risk assessments underpinning visiting policies with residents or their families, including updates on any changes, to help explain the decisions they have made, and their visiting policy. Sharing completed assessments with families may assist in emphasising the need for partnership between families, residents and care homes.

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

Key message

The local DPH and 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 particular 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 bans covering whole local authority areas are not appropriate.

The default position is that visits of all kinds described in this guidance 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 ensuring 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. 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 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 1984, for example the Health Protection (Coronavirus, Restrictions) (Local Authority Enforcement Powers and Amendment) Regulations 2020. 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 than the generic advice set out in this guidance. This should be shared in a clear and simple way with residents and loved ones.

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 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 may make it challenging to follow some of the detailed advice in this guidance on the conduct of visits. 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. This will include residents who lack the capacity to decide who they wish their visitors to be. For example, some people with dementia and learning disabilities may lack the relevant capacity to decide whether or not to consent to a provider’s visiting policy. These residents will fall under the empowering framework of the Mental Capacity Act 2005 (MCA) and are protected by its safeguards. Where appropriate, their advocates or those with power of attorney should be consulted, and if there is a deputy or attorney with relevant authority they must make the best interests decision to consent on the person’s behalf to the visiting policy.

When considering their visiting policy, staff will need to consider the legal, decision-making framework, offered by the MCA, individually for each of these residents and should not make blanket decisions for groups of people. The government has published advice on caring for residents without relevant mental capacity, the MCA and Deprivation of Liberty Safeguards (DoLS) during the pandemic, setting out what relevant circumstances should be considered when making best interest decisions.

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. Essential care givers can continue to visit unless there are specific reasons not to do so.

However, window and pod visits do not necessarily need to be stopped. A risk assessment on window visits during an outbreak should be undertaken to take account of specific circumstances of the care home. It should consider the impact of the outbreak and capability to facilitate window or other visits without breaching zoning or cohorting of residents and staff, which is part of infection control management. Health protection teams, local authority directors of public health, clinical commissioning group infection control leads and other partners provide advice to care homes to help them with such a dynamic risk assessment. Specific measures may change over the course of any outbreak depending on success of containing any outbreak.

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, which will be at least 14 days after the last laboratory confirmed or clinically suspected cases were identified in a resident or member of staff in the home. Recovery testing on all those who had previously tested negative should be carried out 14 days after the last positive test result. If all recovery testing shows negative results, restrictions on visiting should be removed. Where there is an outbreak of a variant of concern (VOC) other than VOC-20DEC-01 [Kent], all visiting will need to stop for 28 days. When visiting resumes the usual infection prevention and control measures and any enhancements required due to any risks identified following the recent outbreak will need to be followed.

Detail about how an outbreak is defined, and the steps that should be taken to manage it can be found as part of the Admission and care of residents in a care home during COVID-19 guidance. In this context, an outbreak is 2 or more confirmed cases of COVID-19 or clinically suspected cases of COVID-19 among individuals associated with a specific setting with onset dates within 14 days.

2. Delivering safe visiting

2.1 Named visitors

Key message

Each resident can nominate up to 5 people for regular visits (including, where relevant, an essential care giver) – as agreed with the care home.

To reduce the risk of infection, residents can have no more than 2 visitors at a time or over the course of one day (essential care givers are exempt from this daily limit).

These visitors should be tested using rapid lateral flow tests on the day of every visit and produce a negative COVID test prior to their visit.

Testing is one way of reducing the risk of visiting a care home, but it does not mean there is no longer any risk. The visitor should also wear appropriate PPE and follow all other infection prevention and control measures.

Visitors are advised to keep physical contact to a minimum. Physical contact like handholding is acceptable if hand washing protocols are followed. Close personal contact such as hugging presents higher risks but will be safer if it is between people who are double vaccinated, without face-to-face contact, and there is brief contact only.

Nominating the named visitors

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

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

Vaccination is one of our best defences to combat infection. It significantly reduces the transmission of infection, particularly after 2 doses. It is strongly recommended that residents and visitors receive 2 doses of the vaccine before conducting visits.

Arrangements for essential care givers are described below in section 2.2.

Conduct of the visit

Care homes are best placed to decide how often and for how long it is possible for visitors to come into the home. This is likely to be determined by practical considerations such as the layout of the home, and the numbers of residents and families who wish to have visits. In practice this is likely to mean that the frequency of visits is limited by setting-specific constraints.

In this context, it is recommended that the care home has a simple booking or appointments system to enable visits. Ad hoc or unannounced visits may not be possible.

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 visitors at a time and are subject to regular enhanced cleaning and ventilation between visits. Any areas used by visitors should be decontaminated several times throughout the day and providers should avoid clutter to aid cleaning.

Visitors should wear appropriate PPE as laid out in the guidance on how to work safely in care homes in England. This guidance sets out the appropriate levels of PPE for a range of scenarios.

Visitors should also be careful to ensure they observe strict social distancing from other residents, visitors and staff at all times.

Testing arrangements for the named visitors

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. 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. Alternative routes may include:

• assisted testing at another lateral flow site such as an asymptomatic testing site (ATS)
• self-testing at home through test kits provided by the care home using packs of 7 test kits (which the MHRA has authorised for self-test use)
• self-testing at home using test kits provided by the government such through a school, workplace, the universal testing offer, or collected from a pharmacy

Care homes are not able to distribute packs of 25 tests to visitors to use for self-test, in line with MHRA rules.

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 and ability 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
• visitors may not 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 on site.

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 unique organisation number (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 the visitor tests positive they and their household must immediately self-isolate, following government guidance for households with possible or confirmed COVID-19 infection. If the test has been taken away from their own home, when returning home, they should avoid public transport and wear a mask. Visitors should also complete a confirmatory polymerase chain reaction (PCR) test which should be provided to them by the care home if testing on site, or ordered from the government portal or by calling 119. Instructions on how to conduct the test and return it will be provided with the test kit. This can be returned either through a courier or through a Royal Mail priority post box. If the confirmatory PCR comes back positive, their contacts may also need to self-isolate. If the follow-up PCR test result is negative, and this PCR test was taken within 2 days of the positive rapid lateral flow test, self-isolation is not necessary.

Where testing will be fully or partly conducted on site, care home managers will need to set up a testing area as described in the guidance above. 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 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.

Visitors who have recently tested positive for COVID-19 from a PCR test should not routinely be retested within 90 days unless they develop new symptoms or unless specific infection detection and response plans are in place for individuals or in the local area already. This means that some visitors will not need to be tested regularly because they will still fall into this 90-day window. These visitors should use the result of their positive PCR result to show that they are currently exempt from testing until the 90-day period is over following their period of self-isolation. Once the 90-day period is over, visitors should then continue to be tested. They should still continue to follow all other relevant IPC measures throughout these 90 days, including social distancing, maintaining good hand hygiene and wearing PPE.

2.2 Essential care givers

Key message

All residents may benefit from a visit from a loved one who provides a greater degree of personal care or support, to maintain their immediate health and wellbeing.

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

Each resident will be different, and the exact arrangements will need to be agreed between the care home, resident and their family (with professional support if helpful). This should follow an individualised assessment of the resident’s needs.

The role of an essential care giver

The essential care giver role is intended as a way of supporting residents to benefit from additional care and support being provided by someone with a unique personal relationship with the resident, perhaps formed over many years. Essential care givers should be allowed to continue to visit during periods of isolation or where there is an outbreak.

The essential care giver arrangements are intended for circumstances where the visitor’s presence, or the care they provide, is central to the immediate health and wellbeing of the resident, and their health or wellbeing could deteriorate without it. It is likely that the requirement for this support from the resident’s loved one will already be part of (and documented in) their care plan – although this should not be considered a condition of this type of visit. Managers should not assume that, in order to fulfil this role, an essential care giver must commit to visiting a specific number of times each day or week – the care and support provided may still be critical even if it is not provided every day.

Each resident’s circumstances will be different and decisions will need to be taken in agreement between the care home, the resident, and family (and other professionals where this is helpful or necessary). In particular, care homes should follow the advice set out in section 1.3 above. They should make an individualised risk assessment for the resident which should include the risk and benefits of proposed visits – and this should be discussed and agreed with the resident’s family (or other interested parties as the case may be). The assumption is that there will only be one essential care giver for one resident – although exceptions may be agreed subject to this assessment of individual circumstances.

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.

More details about the role of the essential care giver can be found in the Partners in Care resources produced by a coalition of providers, relatives and residents organisations facilitated by the National Care Forum.

Further support for essential care givers

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

Therefore, these visitors will need to follow the following testing arrangements:

• take a minimum of 2 rapid lateral flow tests a week: one rapid lateral flow test on the same day as the PCR test, and one rapid lateral flow test 3 to 4 days later, except in the circumstances relating to testing following a prior positive PCR, outlined below. These rapid lateral flow tests can be done onsite, at an asymptomatic testing site (ATS) or at home with tests that come in packs of 7. These tests should be reported as ‘visitor’ using the care home UON

• take a weekly PCR test and share the result with the home. Care homes should use their existing PCR stocks to test these visitors and these should be registered as ‘staff’ tests using the care home UON and be returned via courier with other staff tests

• be subject to additional testing in line with care home staff should the care home be engaged in rapid response daily testing or outbreak testing. If this includes lateral flow tests, these can be done at home with tests from a packs of 7

This testing must be conducted in accordance with the guidance for care home staff on PCR testing, rapid lateral flow testing including rapid response testing, and outbreak testing.

These visitors should use the same PPE as members of the care home staff (including gloves only when providing direct personal care), and should follow the appropriate guidance for using it after being shown how to put it on and take it off correctly, either by video or by a staff member. It is also sensible for the visitor to be observed 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. This remains the case regardless of whether the resident and/or the visitor have received a vaccine. If the resident being visited is believed to have COVID-19, or is coughing, and the visitor will be within 2 metres of them, this should include eye protection such as goggles or a visor.

These visitors must be reminded that PPE is only effective if worn properly, put on and taken off safely, and combined with infection prevention and control measures such as hand hygiene and avoiding touching your face with your hands. Care home staff should provide visitors with guidance on how to safely put on and remove PPE and visitors should also be encouraged to view the video demonstration.

Care home staff should also ensure that these visitors have been provided with appropriate information regarding how frequently they should change their PPE and are supported to change their PPE where necessary, for example changing gloves after supporting a resident with personal care. This must include appropriate guidance on local arrangements for disposing of soiled PPE.

These visitors should also 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 a 2-metre distance from staff and any other residents they might encounter.

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

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

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

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

2.3 Outdoor visiting and ‘screened’ visits

Key message

We also want to provide opportunities for each resident to see more friends and family than just their named visitors or essential care giver. It is important that these additional visits are facilitated in a way that reduces the risks to visitors, residents and staff.

Wherever possible, care homes should continue to enable visits in COVID-secure ways, such as those set out below (including behind substantial screens, in designated visiting pods, behind windows or outdoors).

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

Visits should happen in the open air wherever possible (this might include under a cover such as an awning, gazebo or open-sided marquee). For these visits:

• the visitor and resident should 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 (this means, wherever possible, a room that can be entered directly from outside) can be used. In both these cases, providers must ensure that:

• the visiting space is used by only one resident (accompanied if appropriate by an essential care giver) 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 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 increase transmission risk

• if the resident has an essential care giver, they could sit with the resident while another visitor was on the other side of the screen or window. For some residents, this may help them to recognise and chat with their visitors – improving the visiting experience for everyone

• appropriate PPE should 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) should be maintained at all times – during the visit, and around the care home building and grounds

• high quality IPC practice should 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)

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, 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 carefully, with the assumption that visiting will be enabled to happen not just towards the very end of life, and that discussions with the family take place in good time.

Visits of this nature should be tested using rapid lateral flow tests. For information on how to test, please see the guidance on rapid lateral flow testing in adult social care settings.

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

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 an important 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. The 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 relevant infection prevention control measures.

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 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 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 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 considerations and precautions should be considered and followed when visitors are visiting residents of the home:

• all visitors, and especially essential care givers, should 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 reminded that following infection prevention and control measures (for example, hand washing) are essential even if PPE is worn, they have been vaccinated and/or produced a negative test

• visitors should be supported therefore 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 care homes in England to identify the PPE required for their visiting situation. This remains the case even if both resident and visitor have received a COVID-19 vaccine. Care homes are being provided with PPE to meet these requirements

In most circumstances, supervision of visits by a member of care home will not be necessary. There may be some instances where some degree of supervision is helpful – such as a visitor’s first visit.

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 has tested positive for COVID-19 in the last 10 days, 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 with a rapid lateral flow test should immediately leave the premises and return home, avoiding public transport if possible, to self-isolate. They should be offered a confirmatory PCR test by the care home and if this is positive, their contacts should also self-isolate in line with current guidance.

Screening questions that care homes may wish to ask visitors on arrival are (but not limited to):

• 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 tested positive for COVID-19 in the past 10 days? (Note: if that positive test was from a rapid lateral flow test and was followed by a negative PCR test within 2 days, that would not preclude the visitor coming in)

• 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.

Visits involving children and young people aged under 18

It is possible for someone aged under 18 to be one of the named visitors, if the resident, family and the care home all agree that is appropriate.

It is also possible for a young person under the age of 18 to be an essential care giver – although clearly this would be only be appropriate for older teenagers, and must be with the agreement of the care home manager who must satisfy themselves that the young person is confident, capable and willing to provide the care or support agreed.

We recognise that in some cases it may be difficult for friends and family to make a visit if they are not able to bring children with them. We would not want to unnecessarily restrict residents’ opportunities to see visitors in these situations.

Any visits involving children should be carefully considered by the family. The arrangements for the visit – in particular the numbers involved and where the visit will take place – must be planned and agreed with the care home in advance of the visit.

National restrictions on indoor gatherings must be followed. Find out more about what you can and cannot do.

Where it is reasonable and practicable (that is, depending on the age of the child) any children visiting should wear the same PPE as adult visitors. It is not recommended that face coverings are worn by children under the age of 3 for safety reasons. See advice and guidance on appropriate approaches to LFD testing for children of different ages.

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.

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

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. Visitors should be clear with care homes the best method of communication for them.

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:

• how to prepare for a visit, including 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

• 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 at end of life is being supported by testing – advise 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 or holding hands. However, it is important to understand that all close contact increases risk of transmission.

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 and essential care giver visits only.

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.